
Qass. 
Book. 



COPYRIGHT DEPOSIT 



MINOR SURGERY 



BANDAGING 



INCLUDING 



THE TREATMENT OF FRACTURES AND DISLOCATIONS, THE 

LIGATION OF ARTERIES, AMPUTATIONS, EXCISIONS AND 

RESECTIONS, INTESTINAL ANASTOMOSIS, OPERATIONS 

UPON NERVES AND TENDONS, TRACHEOTOMY, 

INTUBATION OF THE LARYNX, ETC. 



BY 

HENRY R. WHARTON, M.D., 

DEMONSTRATOR OP SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE 
PRESBYTERIAN HOSPITAL, AND THE CHILDREN'S HOSPITAL ; CONSULTING SUR- 
GEON TO THE PRESBYTERIAN ORPHANAGE, AND THE BRYN MAWR 
HOSPITAL ; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION. 



FOURTH EDITION, THOROUGHLY REVISED AND ENLARGED, 
WITH 502 ILLUSTRATIONS. 




LEA BROTHERS & CO., 

PHILADELPHIA AND NEW YDK#, 
1899. 



& 



*SEP 71BW 







41387 



Entered according to the Act of Congress, in the year 1899, by 

LEA. BROTHERS & CO., 
In the office of the Librarian of Congress. All rights reserved. 

TWO COf.. <&Cfcivfc 




If COMH OOPYJ 



DORNAN, PRINTER. 



PREFACE TO FOURTH EDITION. 



The author has been much gratified by the favor- 
able reception which has been accorded to this work, and 
has endeavored in the preparation of the present edition 
to make it worthy of a continuance of that favor. The 
subject-matter has been carefully revised and much new 
material has been added, including a chapter upon Sur- 
gical Bacteriology. From the fact that great attention 
is now directed in our medical ~chools to operative pro- 
cedures upon the cadaver, it 1 seemed advisable to the 
author to add a section upon such operations as can with 
advantage be practised upon the cadaver. These include 
Amputations, Ligations, Excisions, the Introduction of 
Sutures, Intestinal Anastomosis, Tracheotomy and Intu- 
bation, and Operations upon the Bones, Tendons, and 
Nerves. 

The descriptions of these operative procedures are brief, 
and are not intended to take the place of the varied and 
elaborate ones given in special works upon operative sur- 
gery, but they have been introduced to add to the value 



iv PREFACE TO FOURTH EDITION. 

of the work as a hand-book for the use of students in 
their practical work. 

The author desires to express his thanks to Dr. J. H. 
Jopson for assistance in revising the proof-sheets. 

1725 Spruce St., Philadelphia, July, 1899. 



PREFACE TO FIRST EDITION. 



The author has, in this work, endeavored to present, 
in as concise a manner as possible, a description of the 
various bandages, surgical dressings, and minor surgical 
procedures which are employed in the practice of surgery 
at the present time. The preparation and application of 
the antiseptic dressings now most commonly used have 
also received full consideration. The article upon Band- 
aging is fully illustrated with cuts, mostly new and 
taken from photographs, which, it is hoped, will prove 
of value as furnishing an accurate representation of the 
most important bandages used in surgical practice; the 
same is in a measure true of the article upon the dress- 
ing of Fractures and Dislocations, in which many new 
cuts of the same kind appear. 

The work also contains short articles upon Tracheot- 
omy, Intubation of the Larynx, the Ligation of Arteries, 
and Amputations, and, although these procedures are 
scarcely to be included with those of Minor Surgery, it 
is hoped that their description will increase the value 
of the work to medical students, for whose use it has 



vi PREFACE TO FIRST EDITION. 

been prepared. The author's thanks are due to Dr. 
Walter D. Green for his kind assistance in revising 
proof-sheets, and to Mr. James Wood for the skilful 
photographic work used in illustrating several of the 
articles. 

Philadelphia, August, 1891. 



CONTENTS 



PAKT I. 

BANDAGING. 

Varieties of Bandages . 
Bandages for the Head and Neck 
Bandages of the Upper Extremity 
Bandages of the Trunk 
Bandages of the Lower Extremity 
Special Bandages .... 
Fixed Dressings or Hardening Bandages 



PAGES 

23-41 
41-53 
54-68 
69-73 
73-83 
83-91 
91-108 



PART II. 



MINOR SURGERY. 

Surgical Bacteriology ........ 108-120 

Theory of Asepsis and Antisepsis in Wound Treatment . 120-125 

Agents Employed to Secure Asepsis ..... 125-132 

Preparation of Materials Used in Aseptic Operations and 

Dressings 132-139 

Preparation of Gauze Dressings 139-143 

Methods and Dressings Employed in the Treatment of 

Wounds to Secure Asepsis 143-144 

Preparation for Aseptic Operation and Dressing of Wounds 144-158 

Materials Used in Surgical Dressings 158-163 

Procedures Employed in Minor Surgery .... 163-225 

.Anaesthetics 225-244 

Trusses 244-247 



Vlll 



CONTENTS. 



PAGES 

Catheters and Bougies . . . . . . . 247-256 

Sutures 256-271 

Methods of Intestinal Anastomosis 271-274 

Ligatures Used in the Treatment of Vascular Growths . 274-278 

-^-"Treatment of Hemorrhage 278-298 

t Opening and Dressing of Abscesses 298-301 

Shock 301-304 

Dressing of Wounds, Burns and Scalds, Bed-sores, Sprains . 304-316 



PART III. 



FRACTURES. 



General Consideration of Fractures 
Treatment t>f Special Fractures . 
Compound and Ununited Fractures 



316-328 
328-380 
380-386 



PART IV. 

DISLOCATIONS. 



General Consideration of Dislocation* 
Special Dislocations 



386-388 
388-418 



PART V. 

OPERATIONS. 



Ligation of Arteries 
Ligation of Special Arteries 



418-420 
420-450 



PART VI. 



AMPUTATIONS. 

General Consideration of Amputations 
~j-Special Amputations ..... 



450-463 
463-507 



CONTENTS. 



IX 



PART VII. 



EXCISIONS AND RESECTIONS, AND SPECIAL 
OPERATIONS. 



General Consideration of Excisions and Resections 

Special Excisions and Resections . 

Trephining ..... 

Laminectomy .... 

Operations upon Nerves 

Operations upon Tendons 

Removal of the Breast 

Tracheotomy .... 

Laryngotomy .... 

Laryngo-tracheotomy . 

Intubation of the Larynx 

Operations upon the Kidney 

Operations upon the Colon . 

Removal of Appendix Vermiformis 

Lithotomy 

Circumcision .... 
Removal of the Testicle 
Operation for Varicocele 
Cholecystotomy .... 
(Esophagotomy .... 
Gastrostomy .... 
Pyloroplasty .... 
Pylorectomy and Gastro-duodenostomy 
Gastro-enterostomy 
Osteotomy 



Index 



PAGES 

507-510 
510-528 
528-532 
532-533 
533-538 
538-544 
544 
544-551 
551-552 
552-553 
553-558 
558-559 
559-561 
561-563 
563-564 
564-565 
565-566 
566 
566 
566-567 
567-570 
570-571 
571-573 
573-574 
574-576 

577 



PART I. 

BANDAGING 



Bandages. These constitute one of the most widely 
used and important surgical dressings; they are employed 
to hold dressings in contact with the surface of the body, 
to make pressure, to hold splints in place in the treatment 
of fractures and dislocations, and to restore to their nat- 
ural position parts which may have become displaced. 

Bandages may be prepared of various materials, such 
as linen, crinoline, flannel, cheese-cloth or tobacco-cloth, 
rubber-sheeting, or muslin, bleached or unbleached; the 
latter material is the most commonly employed, by reason of 
its cheapness; flannel, from its elasticity, is sometimes used, 
but its employment for bandages is now generally limited 
to its use in dressings for operative work in connection 
with the eye and abdomen, and for a primary roller in the 
application of the plaster-of-Paris dressings. 

Bandages are either simple, when composed of one piece 
of material, such as the ordinary roller-bandage, or com- 
pound, when prepared of one or more pieces, adapted by 
size and shape to peculiar objects. 

Bandages are also described as uniting, dividing, com- 
pressing, expelling, or retaining bandages, according to the 
purposes they serve by their application. 

The importance of being perfectly familiar with the gen- 
eral rules of bandaging and proficient in the application of 
the roller-bandage cannot be overestimated, and both the 
student and general practitioner will never have cause to 

2 



18 



BANDAGING. 



regret the time occupied in learning to apply neatly this 
form of surgical dressing. 

A well-applied bandage adds to the comfort of the pa- 
tient, and the method of its application often secures for 
the physician the confidence both of the patient and of his 
friends, while, on the other hand, a badly applied bandage 
is apt to be uncomfortable and insecure, and to meet with 
their adverse criticism. 

The Roller-bandage. The roller-bandage consists of 
a strip of woven material, prepared from some of the ma- 
terials previously mentioned, of variable length and width 
according to the portion of the body to which it is to be 
applied; this, for ease of application, is rolled into a cylin- 
drical form. 

Fig. 1. 




Bandage-winder. 



The material commonly employed'for the roller-bandage 
is unbleached muslin, although, for special purposes, linen, 
flannel, rubber-sheeting, crinoline, or cheese-cloth may be 
used. Jt is important that the roller-baudage should con- 
sist of one piece, free from seams and selvage, for if made 
of a number of pieces sewed together, or if it contains 
creases or selvage, it cannot be so neatly applied, and it is 
not so comfortable to the patient, as it is apt to leave 
creases upon the skin. 



THE ROLLER-BANDAGE. 



19 



In preparing the ordinary muslin bandage the material 
is torn in strips varying in length and width according to 
the part of the body to which it is to be applied, and it is 
then rolled into a cylinder, either by the hand or by a 
machine constructed for the purpose (Fig. 1). 

It is important that every student and practitioner 
should be able to roll a bandage by hand, for in practice 
the medical attendant may at any moment be called upon 
to prepare a bandage, in order to apply a dressing, and the 
art of preparing a bandage is easily acquired by a little 
practice. To roll a bandage by hand the strip should be 

Fig. 2. 




Rolling a bandage by hand. 

folded at one extremity several times until a small cylinder 
is formed; this is then grasped by its extremities by the 
thumb and index finger of the left *hand; the free ex- 
tremity of the strip is then grasped between the thumb 
and index finger of the right hand, and by alternate pro- 
nation and supination of the right hand the cylinder is 
revolved and the roller is formed; the firmness of the 
roller will depend upon the amount of tension which is 
kept upon the free extremity of the strip during the 
revolution of the cylinder (Fig. 2). A bandage rolled 



20 



BANDAGING. 



in the form of a cylinder is called a single or single-headed 
roller (Fig. 3); if rolled from each extremity toward the 
centre so that two cylinders are formed joined by the 
central portion of the strip, the double or double-headed 
roller is formed (Fig. 4). 



Fig. 3. 



Fig. 4. 






Single roller. 



Double roller. 



Double rollers are not much used, and in practice the 
single roller will be found to be amply sufficient for the 
application of almost all the bandages employed in sur- 
gical dressings. 

The free end of the roller-bandage is called the initial 
extremity ; the end which is enclosed in the centre of the 
cylinder is its terminal extremity ; and the portion between 
the extremities the body ; a roller has also two surfaces, 
external and internal. 

Dimensions of Bandages. Bandages vary in length 
and width, according to the purposes for which they are 
employed, and in practice it will be found that a small 
variety of bandages will be amply sufficient for the appli- 
cation of the ordinary surgical dressings. 

The following list comprises those most frequently used 
and will show their dimensions : 

Bandages one inch wide, three yards in length, for ban- 
dages for the hand, fingers, and toes. 



GENERAL RULES FOR BANDAGING. 21 

Bandages two inches wide, six yards in length, for head- 
bandages and for the extremities in children. 

Bandages two and a half inches wide, seven yards in 
length, for bandages of the extremities in adults; a roller 
of this size is the one most generally used. 

Bandages three inches wide, nine yards in length, for 
bandages of the thigh, groin, and trunk. 

Bandages four inches wide, ten yards in length, for ban- 
dages of the trunk. 

General Rules for Bandaging. In applying a roller- 
bandage the operator should place the external surface of 
the free extremity of the roller upon the part, holding it in 
position with the fingers of the left hand until fixed by a 
few turns of the roller, the cylinder being held in the right 
hand by the thumb and fingers; for thus as the bandage is 
unwound it rolls into the operator's hand, thereby giving 
him more control of it; care should also be taken that the 
turns are applied smoothly to the surface, and that the 
pressure exerted by each turn is uniform. 

When a bandage is applied to a limb the surgeon should 
see that the part is in the position it is to occupy as regards 
flexion and extension when the dressing is completed, for 
a bandage applied when the limb is flexed will exert too 
much pressure when the limb is extended, and then may, 
by the pressure it exerts, become a matter of discomfort or 
even of danger to the patient, or if applied to an extended 
limb it will become uncomfortable upon flexion. 

My experience has been that, as a rule, those who have 
had little experience with the application of the roller- 
bandage are apt to apply their bandages too tightly, and 
this may lead to disastrous consequences; gangrene of the 
extremities having resulted from the too tight application 
of bandages, especially in the dressing of fractures. Pro- 
fessor Ashhurst, in his clinical teaching, advises students 
to make use of a larger number of turns of a bandage in 
securing fracture-dressings rather than to depend upon a 
few turns too firmly applied — advice which certainly con- 
duces to the safety and comfort of the patient. When the 
bandage has been completed the terminal extremity should 



22 



BANDAGING. 



be secured by a pin or safety-pin applied transversely to 
the bandage, and if a pin be used its point should be buried 
in the folds of the bandage; if the bandage be a narrow 



Fig. 5. 




Method of removing a bandage. 



one, the end may be split and the two tails resulting may 
bejsecured around the part by tying. 



Fig. 6. 




Bandage-scissors. 



Removal of Bandages. In removing a bandage the folds 
should be carefully gathered up in a loose mass as the ban- 
dage is unwound, the mass being transferred rapidly from 



VARIETIES OF BANDAGES. 23 

one band to the other, thus facilitating its removal and 
preventing the part from becoming entangled in its loops 
(Fig. 5). If it is desirable to cut the bandage to remove 
it, the use of scissors made for this purpose will be found 
most satisfactory (Fig. 6). 



VARIETIES OF BANDAGES. 

Circular Bandage. This bandage consists of a few 
circular turns around a part, each turn covering accurately 
the preceding turn. This variety of bandage may be used 
to retain a dressing to a limited portion of the head, neck, 
or limbs, to make compression upon the veins of the arm 
before performing venesection, or to secure a compress to 
control venous hemorrhage (Fig. 11, b). 

Oblique Bandage. In this form of bandage the turns 
are carried obliquely over the part, leaving uncovered 
spaces between the successive turns (Fig 7). It cannot 

Fig. 7. 




Oblique bandage. 

be applied with much firmness on account of the uncov- 
ered portions of skin between the turns of the bandage, 
and its principal use is for the application of temporary 
dressings, such as wet dressings which may require fre- 
quent removal. 

Spiral Bandage. In this bandage the turns are carried 
around the part in a spiral direction, each turn overlap- 
ping a portion of the preceding one, usually one-third or 
one-half; it may be applied as an ascending spiral (Fig. 8) 
or as a descending spiral (Fig. 9). This bandage may be 



24 



BANDAGING. 



used to cover a part which does not increase too rapidly in 
diameter; for instance, the abdomen, chest, or arm. 



Fig. 8. 







I 



Ascending spiral bandage. 
Fig. 9. 




Descending spiral bandage. 

Spiral Reversed Bandage. This bandage is a spiral 
bandage, but differs from the ordinary spiral bandage in 
having its turns folded back or reversed as it ascends a 
part the diameter of which gradually increases. By its 
use it is possible to cover by spiral turns a part conical in 
shape, so as to make equable pressure upon all parts of 
the surface. The reverses are made as follows : After 
fixing the initial extremity of the roller, as the part in- 
creases in diameter, the bandage is carried off a little 
obliquely to the axis of the limb for from four to six 
inches; the index-finger or thumb of the disengaged hand 
is placed upon the body of the bandage to keep it securely 
in place upon the limb, the hand holding the roller is car- 
ried a little toward the limb to slacken the unwound por- 
tion of the bandage, and by changing the position of the 
hand holding the bandage from extreme supination to pro- 
nation the reverse is made (Fig. 10). Care should be 



VARIETIES OF BANDAGES. 



25 



taken not to attempt to make the reverse while the ban- 
dage is tense, for by so doing the bandage is twisted into 
a cord which is unsightly and uncomfortable to the patient, 
instead of forming a closely fitting reverse. 

The reverse should be completed before the bandage is 
carried around the limb, and when it has been completed 
the bandage may be slightly tightened so as to conform to 
the part accurately. 

Fig. 10. 




Method of making reverses. 

The reverses should be in line to have the bandage pre- 
sent a good appearance, and care should be takeu that the 
reverses should not be made over prominent bony parts of 
the limb, for if they occupy such positions they cause 
creases in the skin and become uncomfortable to the 
patient. 

To make reverses neatly and to have them in line re- 
quire skill and practice; a well-applied spiral reversed 
bandage is a test of a competent bandager. 

Spica-bandage. When the turns of the roller cross 
each other in the form of the Greek letter lambda, leaving 
the previous turn about one-third uncovered, the bandage 
is known as a spica-bandage (Fig. 11, a). These spica- 



26 



BANDAGING. 



bandages are especially serviceable as a means of retaining 
surgical dressings upon particular portions of the surface 
of the body, such as the shoulder, groin, or foot. 



Fig. 11. 




Spica-bandage. 



Circular bandage. 



Figure-of-eight Bandage. This bandage receives its 
name from the turns being applied so as to form a figure- 
of-eight. This method of application is made use of in 
the Barton's bandage, the bandages of the knee and elbow, 
and many other bandages. 



Fig. 12. 




Recurrent bandage 



Recurrent Bandage. This bandage derives its name 
from the fact that the roller after covering a certain part of 
the surface is reflected and brought back to the point of 
starting; it is then reversed and carried toward the oppo- 



COMPOUND BANDAGES. 



27 



site point, and this manipulation is continued until the 
part is covered by these recurrent turns, which are then 
secured by a few circular turns (Fig. 12). This is the 
bandage usually employed in the dressing of stumps after 
amputation. 

Compound Bandages. 

These baudages are usually formed of several pieces of 
muslin or other material, sewed or pinned together, and 
are employed to fulfil some special indication in the appli- 
cation of dressings to particular parts of the body. The 
most useful of the compound bandages are the T-bandages 
aucl the many-tailed bandages. 

T-bandage. The single T-bandage cousists of a hori- 
zontal band to which is attached, about its middle, another 
having a vertical direction; the horizontal piece should be 



Fig. 13. 



Fjg. 14. 





Single T-bandage. 



Single T-bandage for chest. 



about twice the length of the vertical piece (Fig. 13). The 
single T-bandage may be used to retain dressings to the 
head, the horizontal piece being passed around the head 
from the occiput to the forehead, the vertical piece being 
passed over the head and secured to the horizontal piece, 
the shape and width of the two pieces being varied accord- 
ing to the indications. In applying dressings to the anal 
region or perineum, or in securing a catheter in a perineal 



28 



BANDAGING. 



wound, the single T-bandage will be found most useful. 
In applying a T-bandage for this purpose the body of the 
bandage is placed over the spine, just above the pelvis, and 
the horizontal portion is tied around the abdomen. The 
free extremity is split into two tails for about two-thirds 
of its length, and is carried over the anal region and 
brought up between the thighs, the terminal strips passing 
one on each side of the scrotum and being secured to the 
horizontal strip in front. The single T-bandage may be 

Fig. 15. 




T-bandage of groin. 



variously modified according to the indications which are 
to be met; for instance, in applying a dressing to the 
breasts the horizontal strip passing around the chest may 
be made ten or twelve inches in width; the vertical strip, 
two inches iu width, passes from the back over the shoul- 
der and is secured to the horizontal strip in front (Fig. 14). 
The single T-bandage may be variously modified, accord- 
ing to the ideas of the surgeon, so as to meet the indica- 
tions presented in special cases. For the groin a piece of 



COMPOUND BANDAGES. 



29 



muslin six inches wide at its base and thirty inches long 
is sewed to a horizontal strip of muslin one and a half 
yards long and two inches in width. It may be applied 
as in Fig. 15 to hold a dressing to this part. 

Double T-bandage. The double T-bandage differs 
from the single bandage in having two vertical strips 
attached to the horizontal strip and it may be used for 
much the same purposes as the single T-bandage (Fig. 16). 
It may be conveniently used for retaining dressings to the 
chest, breast, or abdomen; when used for this purpose the 

Fig. 16. 




Double T-bandage. 



horizontal portion should be from eight to twelve inches 
wide and long enough to pass one and a quarter times 
about the chest; two vertical strips, two inches wide and 
twenty inches long, should be attached to the horizontal 
strip a short distance apart near its middle. In applying 
this bandage to the chest, the horizontal strip is placed 
around the chest so that the vertical strips occupy a posi- 
tion on either side of the spine; the overlapping end of the 
horizontal portion is secured by pins or safety-pins, and 
the vertical strips are next carried one over either shoul- 
der and secured to the other portion of the bandage in 
front of the chest (Fig. 17). 

The double T-bandage may also be used to secure dress- 



30 



BAND A GING. 



ings to the nose, in which event the strips should be quite 
narrow, about one inch in width, and should be applied as 
shown in Fig. 18. 



Fig. 17. 



Fig. 18. 





Double T-bandage of chest. 



Double T-bandage of nose. 



Many-tailed Bandages or Slings. These bandages 
are prepared from pieces of muslin of various lengths and 
breadths, which are split at each extremity into two, three, 
or more tails up to within a few inches of their centres, 
their width and length being regulated by the part of the 
body to which they are to be applied. 

The four-tailed bandage may be found useful as a tem- 
porary dressing in cases of fracture of the jaw, or to hold 
dressings to the chin. It may be prepared by taking a 
portion of a roller-bandage three inches wide and one yard 
in length, and splitting each extremity up to within two 
inches of the centre; it is then applied as seen in Fig. 19. 

The four-tailed bandage may also be used to retain dress- 
ings to the scalp, and can be prepared by taking a piece of 
muslin one yard and a quarter long and six or eight inches 
in width, splitting it at each extremity into two tails'within 
six inches of the centre; it may then be applied as seen in 
Fig. 20. 

The four-tailed bandage may also be used in the tem- 
porary dressing of fractures of the clavicle — the body of 



COMPOUND BANDAGES. 



31 



the bandage being placed upon the elbow of the injured 
side, two tails passing around the body, fixing the arm to 
the side, and two tails passing over the sound shoulder. 



Fig. 19. 



Fig 20. 





Four-tailed bandage of chin. 



Four-tailed bandage of head. 



Many-tailed Bandage of Abdomen. This bandage may 
also be used for holding dressings in contact with the abdo- 



Fig. 21. 



:■<> 



4 



^ 





Many-tailed bandage of abdomen. 



men or trunk, and is the bandage which most surgeons 
employ to hold the dressings to a laparotomy-wound, and 



32 



BANDAGING. 



to give support to the abdominal walls after this operation. 
In preparing this bandage, a strip of muslin or flannel, 
one and a half yards in length and eighteen to twenty 
inches in width, is required; the extremities may be split 
so as to form a four or six-tailed bandage. In applying 
this bandage to the abdomen, the body is placed upon the 
patient's back and the tails are brought around the abdo- 
men and overlap each other, and when sufficiently firmly 
drawn to make the desired amount of pressure they are 
secured by means of safety-pins (Fig. 21). 

Handkerchief-bandages. 

The use of handkerchiefs or square pieces of muslin for 
the temporary or permanent dressing of wounds, fractures, 
or dislocations was advocated many years ago by M. 
Mayor, a Swiss surgeon, who wrote an extensive work 



Fig. 22. 



Fig. 23. 



I 

Wr — g —=| | 

"a i" 

m » 

-a * 

1 



1 " = 1rr=" i 




The square. 



The oblong. 



upon this subject, in which he reduced their application to 
a system. He employed a handkerchief or a square piece 
of muslin, and by various modifications in the application 
of these developed a number of very ingenious bandages. 
The various forms which the handkerchief or square 
(Fig. 22) is made to assume are as follows : The oblong, 
made by folding the square once or twice on itself (Fig. 



HANDKER CHIEF-BAN DA GES. 



33 



23). The triangle, made by bringing together the diag- 
onal angles of the square (Fig. 24). The line of folding 
is known as the base, the angle opposite the base the apex, 
and the other angles the extremities. 

The cravat is prepared from the triangle by bringing the 
apex to its base, and folding it a number of times upon 
itself until the desired width is obtained (Fig. 25). 

Fig. 24. 




The triangle. 



The cord is formed from the cravat twisted upon itself 
(Fig. 26). The names of the various handkerchief-ban- 
dages are derived from the shape of the handkerchiefs used 
and the parts to which they are applied; the names serve 
as guides in their application. It is to be remembered 



Fig. 25. 



The cravat. 



Fig. 26. 



The cord. 



'"^S^> 



that the base of the triangle or the body of the cravat is 
to be placed upon the portion, the designation of which 
forms the first portion of the name of the bandage; thus, 
in the occipi to-frontal triangle, the shape of the handker- 

3 



34 BANDAGING. 

chief is given, and we know that the base of the triangle 
is to be applied to the occiput and then pass to the fore- 
head. In using the cravats the same rule applies ; thus, 
in the bis-axillary cravat the body of the cravat is to be 
placed in the axilla of the affected side, the extremities 
crossed over the corresponding shoulder and carried over 
the chest, one before, the other behind, to the axilla of the 
opposite side, where they are secured. 

Fig. 27. 




■■mm- 



/ 



Occipitofrontal triangle. 

The Occipito-frontal Triangle. To apply this hand- 
kerchief, place the base of the triangle upon or a little 
below the occiput, and bring the apex forward over the 
head, allowing it to drop over the forehead; next bring 
the extremities of the handkerchief forward and tie them 
in a knot over the forehead; finally turn up the apex over 
the knotted ends and pin to the body of the handkerchief 
(Fig. 27). 



HANDKER CHIEF-BANDA GES. 



35 



The Mento-vertico-occipital Cravat. To apply this 
handkerchief the middle of the base of the cravat is placed 
under the chin, the extremities are then carried in front of 
the ear on each side to the vertex of the skull, and are 
crossed at that point; the ends are then carried downward 
over the parietal region to the occiput and are secured by 
a knot at this point (Fig. 28). Another method of apply- 



FlG. 28. 



FIG. 29. 




*** 



Mento-vertico-occipital cravat. 



Mento-vertico-occipital cravat (modified). 



ing this handkerchief consists in placing the base of the 
cravat under the chin and carrying the extremities over 
the vertex of the skull, crossing them at that point, then 
carrying them downward to the occiput, and crossing them 
again here and passing them forward around the chin, and 
finally securing the ends by a knot (Fig. 29). The turns 
of the latter handkerchief correspond exactly to the turns 
of the Barton's bandage of the head. 



36 



BANDAGING. 



These handkerchief-bandages may be used to secure 
dressings to the chin or scalp, or may be employed as tem- 
porary dressings to secure fixation of the parts in cases of 
fracture or dislocation of the jaw. 



Fig. 30. 




Bis-axillary cravat. 

The Bis-axillary Cravat. To apply this handkerchief 
the body of the cravat is placed in the axilla, and the ends 
are brought up, one in front of, the other behind, the axilla, 
and are made to cross over the top of the shoulder; the 
extremities are then carried across the back and chest re- 
spectively to the opposite axilla, when they are secured by 
tying (Fig. 30). This handkerchief may be employed to 
secure dressings in the axilla, or to hold dressings in con- 
tact with the shoulder. 



HANDKEB GHIEF-BA NDA GES. 



37 



The Dorso -axillary Cravat. This handkerchief is ap- 
plied by placing the body of the cravat over the spine 
between the scapulae, and then carrying one extremity over 
the shoulder and through the axilla backward to meet the 
other extremity, which has been carried through the axilla 
and over the other shoulder to the back, when the ends are 
secured by a knot (Fig. 31). This handkerchief may be 
used to hold dressings to the axilla or upper portion of the 
back of the chest. 

Fig. 81. 




Dorso-axillary cravat. 



The Compound Dorso-bis-axillary Cravat. To apply 
this handkerchief two cravats are required. The base of 
one cravat is placed over the front of one shoulder, and 
the ends are passed, one over the top of the shoulder, the 
other through the axilla, and they are then secured by a 
single knot over the scapula; the ends are next secured by 
tying them in a loop. The second cravat is next placed 
in front of the shoulder on the opposite side, and the ends 



38 BANDAGING. 

are respectively carried over the shoulder and through the 
axilla to the back, where they are secured by a single knot 
the ends of the handkerchief are then passed through the 
loop of the other handkerchief and secured by a knot (Fig. 
32). This handkerchief may be used to draw the shoul- 
ders backward in cases of dislocation or fracture of the 
clavicle. 

Fig. 32. 




Compound dorso-bis-axillary cravat. 

Triangular Cap or Suspensory of the Breast. To 
apply this handkerchief the base of the triangle is placed 
under the affected breast, and one extremity is carried be- 
neath the axilla of the same side, and the other extremity 
is carried around the opposite side of the neck, and they 
are secured together upon the back by a knot; the apex 
should then be brought up over the breast and shoulder of 
the affected side, and pinned to the bandage over the scap- 
ula (Fig. 33). This handkerchief may be employed to 
sling the breast in nursing-women, or to hold a dressing 
to the breast. 



HANDKEB CHIEF-BAN DA GES. 39 



Fig. 33. 




>■ TT />:■ 



9 




Triangular cap or suspensory of the breast. 

The Gluteo-femoral Triangle. In applying this hand- 
kerchief a cravat is first fastened around the waist, and a 
second handkerchief folded into a triangle has its base 
placed in the gluteo-femoral fold, and its extremities are 
carried around the thigh and secured in front by a knot; 
the apex of the handkerchief is then carried upward and 
passed beneath the cravat around the waist, and is turned 
down and pinned to the body of the triangle (Fig. 34). 
This handkerchief may be used to retain dressings to the 
region of the buttock or hip; by un pinning the apex and 
turning it downward ready access can be had to the parts 
beneath. 

Gluteo-inguinal Cravat. In applying this handker- 
chief the base of the cravat is placed just over the gluteo- 
femoral fold, and the extremities are carried forward, one 



40 



BANDAGING. 



around the inner, the other around the outer portion of 
the thigh, and they are made to cross in the groin; the 
ends are next passed around the pelvis and secured to- 
gether upon the back by a knot (Fig. 35). This handker- 
chief may be employed to hold dressings to the region of 
the groin. 

Fig. 34. 




Gluteo-femoral triangle. 



By employing two cravats a double gluteo-inguinal cra- 
vat may be applied, which may be used to hold dressings 
to both groins. The turns of these cravats correspond to 
the turns of the single and double spica-bandages of the 
groin. 

I have described a few of the many very ingenious ban- 
dages devised by Mayor to substitute the use of the roller- 
bandage, which will give the student some idea of their 
design and application. It is well to bear in mind this 
system of dressing, for the occasion might occur in which 
the ordinary means of bandaging could not.be obtained, 
and the use of handkerchiefs might answer a useful pur- 



BANDAGES FOE THE HEAD AND NECK. 41 

pose as temporary dressings. I think their principal 
use is for temporary dressings, and I do not think they 

Fig. 35. 




Gluteo-inguinal cravat. 



will ever take the place of the roller-bandage, which can 
be applied with much greater nicety and exactness, and 
certainly presents a much neater appearance. 



BANDAGES FOR THE HEAD AND NECK. 

Barton's Bandage. Roller Two Inches in Width, Six 
Yards in Length. The initial extremity of the roller 
should be placed on the head just behind the mastoid pro- 
cess, and the bandage should then be carried under the 
occipital protuberance obliquely upward under and in front 
of the parietal eminence across the vertex of the skull, 
then downward over the zygomatic arch, under the chin, 
thence upward over the opposite zygomatic arch and over 
the top of the head, crossing the first turn which was made, 
as nearly as possible in the median line of the skull, and 
carrying the turns of the roller under the parietal eminence 
to the point of commencement. The bandage is then 
passed obliquely around under the occipital protuberance 
and forward under the ear to the front of the chin, thence 



42 BANDAGING. 

back to the point from which the roller started. These 
figure-of-eight turns over the head and the circular turns 
from the occiput to the chin should be repeated, each turn 
exactly overlapping the preceding one until the bandage 
is exhausted (Fig. 36). The extremity should then be 
secured by a pin; and pins should be introduced at the 
points where the turns cross each other to give additional 
fixation to the bandage. In applying the bandage care 

Fig. 36. Fig. 37. 








i>*# 



Barton's bandage, showing crossing of turns 
Barton's bandage. at vertex. 



should be taken to see that the turns overlap each other 
exactly, and that the turns passing over the vertex cross 
as nearly as possible in the median line of the skull 
(Fig. 37). 

Modified Barton's Bandage. To obtain additional 
security in the application of the Barton's bandage a turn 
of the bandage passing from the occiput to the forehead 
may be made, this turn being interposed between the turns 



BANDAGES FOB THE HEAD AND NECK. 43 

of the bandage as ordinarily applied (Fig. 38). In ap- 
plying tills bandage, after the first set of turns has been 
completed — that is, after the bandage has been brought 
back to the occiput, the bandage is carried forward upon 
the head just over the ear, around the forehead and back- 
ward above the ear on the opposite side to the occiput; 
this being done, the ordinary figure-of-eight and circular 

Fig. 38. 



■ W 



w^ 




i 



Modified Barton's bandage. 

turns are made, and when these have been completed 
another occipito-frontal turn may be made as described 
above, and this may be repeated as often as is desired 
until the bandage is exhausted, when the extremity is fast- 
ened with a pin, and pins are also introduced at all points 
at which the turns cross. 

Use. This bandage is one of the most useful of the 
bandages of the head, being employed to secure fixation 
of the jaw in cases of fracture or dislocation, and for the 



44 BANDAGING. 

application of dressings to the chin. I have also employed 
it in place of the head-gear in slinging patients for the 
application of the plaster-of- Paris bandage in cases of dis- 
ease of the spine, a stout cord or a piece of bandage about 
three inches wide and one yard long being passed under 
the turns crossing over the vertex; this cord is then se- 
cured to the cross-bar of the extension apparatus (Fig. 39). 
This will be found quite as comfortable to the patient as 

the ordinary head-gear employed 
FlG - 39 - and much less likely to slip out 

of place and interfere with the 
breathing of the patient. 

A firmly applied Barton's 

/ * ■■ -\\ bandage holds the jaws so closely 

together that care should be taken 

A in applying it to patients who are 

\uima-- - under the influence of an anses- 

^V^- thetic, for if vomiting occurs the 

^S£$ material may not be able to escape 

\ ***V. from the mouth, and suffocation 



\ 



J^r^ 



Y might occur unless the bandage 

were promptly removed. This 

I accident I once saw occur, and 

the patient's condition was alarm- 
Barton's head bandage employed J until th bandao;e was cut 

for suspension. (Park.) .P , , . & . I 

allowing the jaw to be opened 
and the contents of the mouth to escape. 

Gibson's Bandage. Roller Two Inches in Width, Six 
Yards in Length. The initial extremity of the roller 
should be placed upon the vertex of the skull in a line 
with the anterior portion of the ear; the bandage is then 
carried downward in front of the ear to the chin, and 
passed uuder the chin, and is carried upward on the same 
line until it reaches the point of starting. The same 
turns are repeated until three complete turns have been 
made; the bandage is then continued until it reaches a 
point just above the ear, when it is reversed and is carried 
backward around the occiput, and is continued around the 
head and forehead until it reaches its point of origin; 



BANDAGES FOB THE HEAD AND NECK. 



45 



Fig. 40. 



/ A. 

# mm- 



these circular turns are applied until three have been 
made. When the bandage reaches the occiput, having 
completed the third turn, it is allowed to drop down to 
the base of the skull, and it is then carried forward below 
the ear and around the chin, being brought back upon the 
opposite side of the head and neck to the point of origin; 
these turns are repeated until three complete turns have 
been made, and upon the completion of the third turn the 
bandage is reversed and car- 
ried forward over the occiput 
and vertex to the forehead, 
and its extremity is here se- 
cured with a pin. Pi ns should 
also be applied at the points 
where the turns of the band- 
age cross each other (Fig. 40). 

Use. This bandage may 
be used to fix the lower jaw 
in cases of fracture or dislo- 
cation of the jaw, but is very 
apt to change its position, and 
is, therefore, not so satisfac- 
tory as the Barton's bandage 
for this purpose. 

Oblique Bandage of the Angle of the Jaw. Roller Two 
Inches in Width, Six Yards in Length. The initial extrem- 
ity of the roller is placed just in front of and above the 
left ear, and if the left angle of the lower jaw is to be 
covered in, the bandage is to be carried from left to right, 
making two complete turns around the cranium from the 
occiput to the forehead. If, however, the right angle of 
the lower jaw is to be covered in, the turns should be made 
in the opposite direction. 

Having made two turns from the occiput to the fore- 
head, the bandage is allowed to drop down upon the neck, 
and is carried forward under the ear and under the chin 
to the angle of the jaw; it is now carried upward close to 
the edge of the orbit, and obliquely over the vertex of the 
skull, then down behind the right ear, continuing this 



Gibson's 



icUure . 



46 BANDAGES. 

oblique tarn under the chin to the left angle of the jaw, 
where it ascends in the same direction as the previous turn. 
Three or four of these oblique turns are made, each turn 
overlapping the preceding one and passing from the edge 
of the orbit toward the ear until the space is covered in; 
the bandage is then carried to a point just above the ear 
on the opposite side, is reversed, and finished with one or 
two circular turns from the occi- 
put to theforehead, the extremity 
being secured by a pin (Fig. 41). 
Use. This will be found to be 
one of the most useful of the band- 
ages; it may be used with a com- 
press in treating fractures of the 
angle of the lower jaw, for hold- 
ing dressings to the lower part of 
the chin and to the vault of the 
cranium, and is especially useful 
in retaining dressings to the sides 
of the face and the parotid region. 
As before stated, it may be ap- 

Oblique bandage of the angle of P Ued . to C0Ver either the ri g ht 0r 

the jaw. left side of the face, and, by rea- 

son of the oblique turns, holds 
its position most securely, having little tendency to be- 
come displaced. 

Recurrent Bandage of the Head. Roller Two Inches 
in Width, Six Yards in Length. The initial extremity of 
the roller is placed upon the lower part of the forehead 
and the bandage is carried twice around the head from the 
forehead to the occiput to secure it. When the bandage 
is brought back to the median line of the forehead it is 
reversed and the reversed turn is held by the finger of the 
left hand while the roller is carried over the top of the 
head along the sagittal suture to a point just below the 
occipital protuberance; here it is reversed again and the 
reverse is held by an assistant while the roller is carried 
back to the forehead in an elliptical course, each turn cov- 
ering in two-thirds of the preceding turn. These turns 





BANDAGES FOR THE HEAD AND NECK. 47 

are repeated with successive reverses at the forehead and 
occiput until one side of the head is completely covered 
in, and when this is accomplished a circular turn is made 
from the forehead to the occiput to hold the reverses in 
place. 

The opposite side of the head is next covered in by ellip- 
tical reversed turns made in the same manner, and when 
this has been accomplished two or three circular turns are 
carried around the head from the forehead to the occiput 
to fix the previous turns. Pins should be applied at the 
forehead and occiput at the points where the reversed turns 
concentrate (Fig. 42). 

Fig. 42. 




Recurrent bandage of the head. 

Use. This bandage when well applied is one of the 
neatest of the head-bandages, and it will be found useful 
to retain dressings to the vault of the cranium in the treat- 
ment of wounds of the scalp in this region. It will also 
be found of service in holding dressings to fractures of the 
cranium and to wounds after the operation of trephining. 
In restless patients it will sometimes become displaced, and 
it may be rendered more secure by pinning a strip of ban- 
dage to the circular turn in front of the ear and carrying 



48 



BANDAGES. 



Fig. 43. 



it down under the chin and up to a corresponding point 
on the opposite side, where it is pinned to the circular 
turn; or one or two oblique turns passing from the circu- 
lar turn over the vertex of the skull downward behind 
the ear, under the chin and up to the circular turn in front 
of the ear, may be applied. The course of these turns is 
the same as those employed in the oblique bandage of the 
angle of the jaw, the extremity being secured by a pin. 

Transverse Recurrent Bandage of Head. Roller Two 
Inches in Width, Six Yards in Length. The initial extrem- 
ity of the roller is placed upon the lower part of the fore- 
head and the bandage is carried twice around the head 

from the forehead to the occi- 
put to secure it. The head is 
then covered in by transverse 
turns of the bandage; the first 
turn, starting from a point be- 
hind the ear on one side, is 
carried below the occiput to a 
corresponding point behind the 
opposite ear, and ascending 
transverse turns are then made 
and carried over the head, each 
turn covering in about two- 
thirds of the preceding turn, 
until the forehead is reached, 
and when this has been reached 
two or three circular turns are 
carried around the head from the forehead to the occiput 
to fix the recurrent turns. Pins should be applied at the 
points of starting and finishing of the reversed turns be- 
hind the ears, and at the occiput and forehead (Fig. 43). 
Use. This bandage may be employed to secure dress- 
ings to the scalp in cases of wounds, or in injuries to the 
skull, and is used for the same purposes as the recurrent 
bandage of the head. 

V bandage of the Head. Roller Two Inches in Width, 
Four Yards in Length. The initial extremity of the roller 
is secured by two turns of the bandage around the era- 




Transverse recurrent bandage of 
the head. 



BANDAGES FOE THE HEAD AND NECK. 



49 



nium from the forehead to the occiput, arid when the 
roller reaches the occipital protuberance it is allowed to 
drop a little below this, and is carried forward below 
the ear around the front of the chin and lower lip, then 
backward to the point of starting- These turns passing 
from the occiput to the forehead and from the occiput to 
the chin are alternately made until a sufficient number 
have been applied, and the extremity is secured by a pin 
over the occiput (Fig. 44). 

This bandage may be modified by carrying the turns 
from the occiput forward under the ear and around the 
upper lip and back to the occiput and alternating these 
turns with the occipito-frontal turns; if employed in this 
way, a bandage of one and one-half inches in width should 
be used. 

Use. This bandage may be employed to hold dressings 
to the front of the chin, to the upper and lower lips in 
cases of wounds, or to give support to these parts after 
plastic operations. 



Fig. 44. 



Fig. 45. 





V-bandage of the head. 



Head-and-neck bandage. 



Head-and-neck Bandage. Boiler Two Inches in Width, 
Four Yards in Length. The initial extremity of the roller 
is placed upon the forehead and carried backward just 

4 



50 BANDAGES. 

above the ear to the occiput and is then brought forward 
around the opposite side of the head to the point of start- 
ing. Two of these circular turns are made to fix the 
bandage, and when it is carried back to the occiput it is 
allowed to drop down slightly upon the neck, and is then 
carried around the neck, the turns around the head alter- 
nating with the neck-turns until a sufficient number of 
these have been applied, when the extremity of the ban- 
dage is secured by a pin at the point of crossing of the 
turns at the back of the head (Fig. 45). 

Use. This bandage may be found useful in securing 
dressings to the anterior or posterior portion of the neck 
or to the region of the occiput. 

Care should be taken to apply it in such a manner that 
too much pressure is not made by the turns around the 
neck, which would be uncomfortable to the patient, and 
might seriously interfere with respiration. 

Crossed Bandage of One Eye. Roller Two Inches in 
Width, Four Yards in Length. The initial extremity of 
the bandage is placed upon the forehead and fixed by two 
circular turns passing around the 
F,G - 46 - head from the occiput to the fore- 

^0^ head ; the roller is then carried 

J|F back to the occiput and passed 

Jf \ around this and brought forward 

below the ear, and passing over 
the outer portion of the cheek is 
/ / carried upward to the junction of 

*<*;<* the nose with the forehead, and is 

r ■» * »■ « then conducted over the parietal 

, I *. eminence downward to the occi- 

k Ij few put ; a circular fronto-occipital 

^^^HB * s turn is next made, and when the 

crossed bandage of one eye. bandage is brought back to the oc- 
ciput it is brought forward again 
to the cheek. It should then ascend to the forehead, 
covering in two-thirds of the previous turn, and be again 
conducted back to the occiput; these turns are repeated, 
the oblique turns covering the eye alternating with circu- 



BANDAGES FOB THE HEAD AND NECK. 51 

lar turns around the head until the eye is completely en- 
closed (Fig. 46), and the bandage is finished by making a 
circular turn about the head and introducing a pin to 
secure its extremity. It will be found more comfortable 
to the patient to include the ear on the same side on which 
the eye is covered in the turns of the bandage. 

Use. This bandage will be found useful in retaining 
dressings to one eye. It will be more comfortable to the 
patient if a flannel roller be used to apply this bandage, as 
well as the bandage which includes both eyes. 

Crossed Bandage of Both Eyes. Roller Tioo Inches 
in Wi(lth, Six Yards in Length. The initial extremity of 
the roller is placed upon the forehead and secured by two 
circular turns of the bandage, passing around the head 
from the forehead to the occiput; the roller is then carried 
downward behind the occiput and brought forward below 
the ear to the upper portion of the cheek; it is then car- 
ried upward to the junction of the nose with the forehead 
and conducted over the parietal eminence to the occiput; 
a circular turn is now made around 
the head from the occiput to the 
forehead, and the roller is carried 
from the occiput over the parietal 
eminence of the opposite side for- 
ward to the junction of the nose 
with the forehead, then downward ■■■■•-* 
over the eye and outer portion of ^Jr ■'/>/ |f 

the cheek below the ear and back to £ _ ^^ 

the occiput; a circular turn around 
the head is next made, and this is > * ■ <*m*ri* - 

followed by a repetition of the pre- "v ^ 

vious turns, ascending over one eye, jA Bfci 

descending over the other eye, each ^H^. *> ^^ 

turn alternating with a circular Crossed bandage of both eyes. 

turn around the head. These turns 

are repeated until both eyes are covered in, and the band- 
age is finished by making a circular turn around the head, 
the extremity being secured by a pin (Fig. 47). In this 
bandage both ears may be covered in, or left uncovered. 




52 



BANDAGES. 



Use. This bandage may be used to apply dressings to 
both eyes, and both of these bandages covering the eyes 
are used where it is desired to make pressure; but, for the 
simple application of a light dressing or of a bandage for 
the exclusion of light, the Liebrich's bandage (Fig. 86) 
will be found more comfortable to the patient. 

Occipito -facial Bandage. Roller Two Inches in Width, 
Four Yards in Length. The initial extremity of the roller 
is placed upon the vertex of the head and the bandage is 
carried downward in front of the ear, under the jaw, and 
upward upon the opposite side in the same line to the ver- 
tex; two or three of these turns are made, one turn accu- 
rately covering in the other. A reverse should be made 
just above and in front of the ear, and two or three turns 
are then made around the head from the occiput to the 
forehead, which completes the bandage (Fig. 48). Pins 
should be inserted at the points where the turns of the 
bandage cross each other. 

Use. This bandage is employed to secure dressings to 
the vertex, temporal, occipital, or frontal region. 



Fig. 48. 



Fig. 49. 





Occipito-facial bandage. 



Oblique bandage of the head. 



Oblique Bandage of the Head. Roller Two Inches in 
Width, Six Yards in Length. The initial extremity of the 



BANDAGES FOB THE HEAD AND NECK. 



53 



Fig. 50. 



bandage is placed upon the forehead, and is secured by 
two circular turns passing around the head from the fore- 
head to the occiput. From the occiput the bandage is 
carried obliquely over the highest part of the lateral aspect 
of the head, which is to be covered in, and is passed over 
the forehead and back to the occiput. It is then carried 
to the forehead by a circular turn, which is conducted 
obliquely over the other side of the head and back to the 
occiput. A circular turn from the occiput to the forehead 
should be made between the oblique turns. These turns 
are repeated, so that each succeeding turn covers in three- 
fourths of the preceding turn until the sides of the head 
are covered in by descending turns, and the bandage is 
completed by a circular turn passing around the head from 
the forehead to the occiput (Fig. 
49). This bandage may be ap- 
plied with descending or ascend- 
ing turns. 

Use. This bandage is employed 
to make a pressure upon, or to 
hold dressing to the lateral aspects 
of the head. 

Occipto - frontal Bandage. 
Roller Two Inches in Width, Four 
Yards in Length. The initial ex- 
tremity of the roller is placed 
upon the forehead, and a circular 
turn is made around the fore- 
head and occiput to fix it. A 
circular turn is then made, pass- 
ing around the head from a point 
below the occiput to a point just above the forehead ; the 
next circular turn is made around the head ascending 
posteriorly and descending anteriorly, and after a suffi- 
cient number of these turns have been made to cover in 
the front and back of the head, the end of the bandage 
is secured with a pin (Fig. 50). 

Use. This bandage will be found useful in securing 
dressings to the forehead and anterior and posterior por- 
tions of the scalp. 




Occipito -frontal bandage. 



54 BANDAGES. 



BANDAGES OF THE UPPER EXTREMITY. 

Spiral Bandage of the Finger. Roller One Inch in 
WidtJi, One and a Half Ya?*ds in Length. The initial ex- 
tremity of the roller is se- 
f *g. 51. cured by two or three turns 

around the wrist ; the 
bandage is then carried 
obliquely across the back 
of the hand to the base of 
the finger to be covered 
in, then to its tip by ob- 
lique turns; a circular turn 
is next made and the 
finger is covered by as- 
cending spiral or spiral 
reversed turns until its 
base is reached; the ban- 
dage is then carried ob- 
liquely across the back of 
the band and finished by 
one or two circular turns 
spiral bandage of the fioger. around the wrist; the ex- 

tremity may be pinned or 
may be split into two tails, which are tied around the 
wrist (Fig. 51). 

Use. This bandage is employed to retain dressings to 
injuries or wounds upon the finger and to secure splints 
in the treatment of fractures or dislocations of the 
phalanges. 

Gauntlet Bandage. Boiler One Inch in Width, Three 
Yards in Length. The initial extremity of the roller is 
fixed at the wrist by one or two circular turns of the ban- 
dage; it is then carried down to the tip of the thumb by 
an oblique turn of the roller, and this is covered in by 
spiral or spiral reversed turns to the metacarpo-phalangeal 
articulations; the roller is then carried back to the wrist 
and a circular turn is made around it. The bandage is 




BANDAGES OF THE UPPER EXTREMITY. 55 

then carried down to the tip of the index finger by 

an oblique turn, which is covered in the same manner. 

When all the fingers have 

been covered in, the bandage FlG - 52 - 

is finished by circular turns 3 . 

around the hand and wrist gm* ' 

(Fig. 52). _ 

Use. This bandage may be 
employed to apply dressings ^ r 

to the fingers and hand in \ } 

cases of wounds or fractures. J**» 

It was formerly much em- 
ployed in the treatment of 
burns of the fingers to pre- 
vent the opposed ulcerated 
surfaces from adhering, but 
its use for this purpose has 
been supplanted by wrapping 
each finger in a separate 

dressing and applying a dress- '" *"*•* 

ing over all the fingers and Gauntlet bandage. 

the hand with a few recur- 
rent and spiral turns of a wide roller, the application of this 
dressing being much less painful to the patient, and being 
at the same time equally satisfactory in its results. 

Demi-gauntlet Bandage. Roller One Inch in Width, 
Four Yards in Length. The initial extremity of the ban- 
dage should be placed upon the wrist and fixed by two 
circular turns passing from the ulnar to the radial side; 
then carry the roller obliquely across the back of the hand 
to the base of the thumb, pass the bandage around this 
and carry the roller back to the wrist, making a circular 
turn; it should then be carried obliquely across the hand 
to the base of the index-finger, and so successively until 
the base of each of the fingers and of the little finger has 
been included; the bandage is then completed by an oblique 
turn across the back of the hand passing between the index- 
finger and the thumb and a circular turn around the wrist 
(Fig. 53). 



56 BANDAGES. 

The demi-gauntlet bandage may also be applied in such 
a manner as to cover only the palm and leave the dorsum 
of the hand uncovered. 

Use. This bandage may be employed to retain light 
dressings to the dorsal or palmar surface of the hand. 



Fig. 53. Fig. 54. 



' 



"\ % 





Spica- bandage of the 
Demi-gauntlet bandage. thumb. 



Spica-bandage of the Thumb. Roller One Inch in 
Width, Three Yards in Length. The initial extremity of 
the roller is placed upon the wrist and fixed by two circu- 
lar turns; then carry the roller obliquely over the dorsal 
surface of the thumb to its distal extremity; next make a 
circular or spiral turn around the thumb, and carry the 
bandage upward over the back of the thumb to the wrist, 
around which a circular turn should be made. The roller 
is then carried around the thumb and wrist, making figure- 
of-eight turns, each turn overlapping the previous one two- 
thirds as it ascends the thumb, and each figure-of-eight 
turn alternating with a circular turn around the wrist. 
These turns are repeated until the thumb is completely 



BANDAGES OF THE UPPER EXTREMITY. 57 

covered in with spica-turns, and the bandage is finished by 
a circular turn around the wrist (Fig. 54). 

Use. This bandage is employed to apply dressings to 
the dorsal surface of the thumb and for the retention of 
splints in the dressings of fractures or dislocations of the 
bones of the thumb. 

Spiral Reversed Bandage of the Upper Extremity. 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. The initial extremity of the roller is placed upon 
the wrist, and secured by two turns around the wrist; the 
bandage is then carried obliquely across the back of the 
hand to the second joint of the fingers, where a circular 
turn should be made; the hand is covered in by two or 



Frc. 55. 



' 




Spiral reversed bandage of the upper extremity. 



three ascending spiral or spiral reversed turns. When the 
thumb has been reached, its base and the wrist are covered 
in by two figure-of-eight turns; the bandage is then carried 
up the forearm by spiral and spiral reversed turns until the 
elbow is reached; this may be covered in with spiral re- 
versed turns, and the bandage is next carried up the arm 
with spiral reversed turns to the axilla (Fig. 55). If, on 
reaching the elbow, the arm is bent, or is to be flexed in 
the subsequent dressing, the elbow should be covered in 
with figure-of-eight turns, and when this has been done 
the arm may be covered in with spiral reversed turns. 
When properly applied, the reverses should be in line, 



58 



BANDAGES. 



and should not be made over the prominent ridge of the 
ulna. 

Use. This is one of the most generally employed of all 
the roller-bandages; it constitutes the primary roller which 
is applied in the dressing of fractures of the humerus, and 
it is also the bandage employed in holding dressings to the 
arm and forearm and in securing splints to these parts in 
the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Elbow. Holler Tivo 
Inches in Width, Four Yards in Length. The initial ex- 

Fig. 56. 




Figure-of-eight bandage of the elbow. 



tremity of the bandage is placed upon the forearm a short 
distance below the elbow-joint, and fixed by one or two 
circular turns, the arm being flexed. The bandage is then 
carried by an oblique turn across the flexure of the elbow- 



BANDAGES OF THE UPPER EXTREMITY. 59 

joint, and passed around the arm a few inches above the 
elbow; a circular turn is then made, and the roller is next 
carried across the flexure of the elbow and passed around 
the forearm. These turns are repeated, the turns from the 
forearm ascending and those from the arm descending, 
each set of turns crossing in the flexure of the elbow until 
it is covered in, aud a final turn is passed circularly around 
the elbow-joint (Fig. 56). This bandage is sometimes ap- 
plied by first making one or two circular turns around the 
elbow and then applying the figure-of-eight turns as pre- 
viously described. 

Use. This bandage is often employed as a part of the 
spiral reversed bandage of the upper extremity when the 
arm is to be flexed, and is also used to hold dressings to 
the region of the elbow-joint. It was formerly much used 
to hold the compress upon the wound resulting from vene- 
section at the elbow. 

Spica-bandage of the Shoulder (Ascending). Roller 
Two and a Half Inches in Width, Seven Yards in Length. 
The initial extremity of the roller is placed obliquely upon 
the outer surface of the arm opposite the axillary fold, and 
fixed by one or two circular turns. If the right shoulder 
is to be covered, the bandage is next carried across the 
front of the chest to the axilla of the opposite side, then 
around the back of the chest to the point of starting upou 
the arm; then the roller should be conducted around the 
arm of this side up over the shoulder, across the front of 
the chest, through the opposite axilla and back over the 
posterior surface of the chest to the point of starting; con- 
tinue to make these ascending turns, each turn overlapping 
the preceding one about two-thirds until the shoulder is cov- 
ered in (Fig. 57), Avhen the extremity of the bandage may 
be secured by a pin at the point of ending, or the last turn 
may be carried from the shoulder around the back of the 
neck and brought forward over the opposite shoulder and 
pinned to the turns which pass around the axilla. It should 
be remembered that the turns of the roller overlap each 
other exactly in the opposite axilla, and it will be found 
more comfortable to the patient to apply a little cotton- 



60 BANDAGES. 

wadding in the axilla to prevent the bandage from exco- 
riating the skin of this part. Care should be taken to see 
that the turns are made in such a manner that the spica- 
turns occupy, as nearly as possible, the median line of the 
shoulder. When this bandage is applied to the left shoul- 

Fig. 57. 




Spica-bandage of shoulder (ascending). 

der, after fixing the initial extremity by circular turns 
around the arm, the roller should be carried over the back 
of the chest to the axilla of the opposite side and then 
brought back to the point of starting; the succeeding turns 
are then applied in the same manner. 

Spica-bandage of the Shoulder (Descending). Roller 
Two and a Half Inches in Width, Seven Yards in Length. 
The initial extremity of the roller should be fixed upon 
the arm as near as possible to the axillary fold by one or 
two circular turns; and if it is applied to the right shoul- 
der, the bandage should be passed under the axilla and 
carried obliquely over the shoulder to the base of the neck, 
then downward across the front of the chest to the axilla 
of the opposite side; from the axilla the roller is carried 
over the back of the chest to the base of the neck so as to 



BANDAGES OF THE UPPER EXTREMITY. 61 

cross the first tarn at this point; it is then carried through 
the axillary space, then back to the neck, the turns de- 
scending toward the shoulder. These turns, taking the 
same course, are repeated, each turn overlapping two-thirds 
of the previous one until the shoulder is covered in and 
the circular turn around the arm is reached, at which point 
the extremity is secured by a pin (Fig. 58). 



Fig. 58. 




Spica- bandage of shoulder (descending). 

Use. The spica-bandages of the shoulder are employed 
to hold dressings to the shoulder, to hold compresses over 
the acromial end of the clavicle in case of dislocation of 
that portion of the bone, to retain the shoulder-cap used 
in the treatment of fractures of the upper portion of the 
humerus, and to retain dressings to the axilla. 

Figure-of-eight Bandage of the Neck and Axilla. 
Roller Tivo Inches in Width, Five Yards in Length. The 
initial extremity of the roller is fixed upon the side of the 
neck and secured by one or two loosely applied circular 
turns; if applied to the right axilla, carry the bandage from 
left to right over the right shoulder to the anterior part of 
the axilla under which it passes, to ascend in front over 




62 BANDAGES. v 

the same shoulder to the back of the neck; these figure-of- 
eight turns around the neck and axilla, each turn overlap- 
ping two-thirds of the previous turn, are repeated until 

the desired space is covered 
and the bandage is completed 
by a circular turn around the 
neck (Fig. 59). 

Use. This will be found a 
useful bandage to secure dress- 
ings to the base of the neck, 
the upper part of the shoulder, 
and to the axilla, as it does 
not restrict the motions of the 
arm unless drawn too tight. 
Velpeau's Bandage. Two 
Figure-of-eigbt bandage of the Rollers Two and a Half Inches 
neck and axilla. in Width, Seven Yards in 

Length. The patient should 
place the fingers of the hand of the affected side on the 
opposite shoulder ; the initial end of the roller should 
be placed on the body of the scapula of the sound side 
and secured by a turn made by carrying the bandage 
over the shoulder of the affected side, near its outer por- 
tion, then conducting it downward over the outer and pos- 
terior surface of the arm of the same side, behind the point 
of the elbow, and obliquely across the front of the chest to 
the axilla of the opposite side, thence to the point of start- 
ing. This turn should be repeated, to fix the initial ex- 
tremity of the bandage. Having completed the second 
turn, carry the roller transversely around the thorax, pass- 
ing over the flexed elbow of the affected side, from this 
point to the axilla, and through this to the back. From 
this point the roller is carried over the shoulder and down 
the outer and posterior surface of the arm behind the elbow 
and obliquely across the front of the chest through the 
axilla to the back, and continuing, passes transversely 
across the back of the chest to the elbow, which it encir- 
cles, then passes to the axilla. These alternating turns are 
repeated until the arm and forearm are bound firmly to the 



BANDAGES OF THE UPPER EXTREMITY. 



63 



side and chest. The vertical turns over the shoulder, each 
turn covering in two-thirds of the previous turn and as- 
cending from the point of the shoulder toward the neck 
and from the posterior surface of the arm toward the 
elbow, are applied until the point of the elbow is reached. 
The transverse turns passing around the chest and arm are 
so applied that they ascend from the point of the elbow to- 
ward the shoulder, each turn covering in one-third of the 
previous one, and the last turn should pass transversely 
around the shoulder and chest, covering the wrist (Fig. 
60). 



Fig. 60. 




Velpeau's bandage. 



The extremity of the bandage should be secured by a 
pin where it ends, and additional fixation will be secured 
by introducing a number of pins at the points where the 
turns of the bandage cross each other. 

Use. This bandage is employed to fix the arm in the 
treatment of certain fractures of the clavicle and scapula, 
also to secure fixation of the humerus after the reduction 
of dislocations of the shoulder-joint. , 

Desault's Bandage. Three Rollers Two and a Half 
Inches in Width, Seven Yards in Length. A wedge-shaped 



64 BANDAGES. 

pad to fit in the axilla is also required. These rollers are 
known as the first, second, and third rollers. 

First Roller of Desault's Bandage. Before applying the 
first roller the arm of the patient on the injured side should 
be elevated and carried off at right angles to the body; the 
wedge-shaped pad with its base in the axilla should next 
be applied to the side of the chest, and the initial extrem- 
ity of the roller should be placed upon the middle of the 
pad, which may be fixed by two or three circular turns 
around the chest; the bandage is then carried down the 
chest by oblique circular turns until the lower extremity 
of the pad is reached, and it is then carried up the chest 

Fig. 61. 




First roller of Desault's bandage. 

until the upper extremity of the pad is reached, when it 
is conducted obliquely across the front of the chest to the 
sound shoulder and passed under the axilla, brought over 
the shoulder and conducted around the chest, where it is 
secured (Fig. 61). 

Second Roller of Desault's Bandage. The arm should be 
brought down against the side so as to press upon the pad 
previously applied, and the forearm should be flexed upon 
the arm and brought across the lower portion of the chest. 
The initial extremity of the roller is placed in the axilla 
of the sound side, and the bandage is carried around the 



BANDAGES OF THE UPPER EXTREMITY. 



65 



chest and over the arm of the injured side, making a cir- 
cular turn around the chest to fix it; then spiral turns are 
made around the chest from above downward until the 
elbow is reached, the turns being more firmly applied as 
they descend, and when this point is reached the end 



Fig. 62. 




Second roller of Desault's bandage. 



of the bandage is secured. Or the iuitial extremity of 
the bandage may be placed upon the chest of the sound 
side and a circular turn may be made to fix it, and then 
spiral turns, including the chest and arm, may be made 
from below upward until the axilla is reached (Fig. 62). 

Third Roller of Desault's Bandage. The initial extremity 
of the roller is placed in the axilla of the sound side, and 
the bandage is carried obliquely over the frontjQ£ jhe che st 
to the shoulder of the injured side, passed over this, and 
conducted down the back of the arm to the elbow, thence 
obliquely upward over the upper fifth Of the forearm to 
the axilla of the sound side. From this point it is carried 
backward obliquely over the back of the chest to the shoul- 
der; crossing the previous shoulder-turn, it is conducted 
down the front of the arm to the elbow, then around this 
and backward obliquely over the back of the chest to the 

5 



66 BANDAGES. 

axilla of the sound side. These turns are repeated until 
three sets of turns have been applied, which should overlie 
each other exactly (Fig. 63). The course of the turns of 
the third roller is considered the most difficult to remem- 
ber, and the student may be assisted in its correct applica- 
tion by remembering that all the turns start at the axilla, 
pass to the shoulder, and then to the elbow, and from the 
elbow always return to the starting-point — the axilla. 

Fig. fi3. 




Third roller of Desault's bandage. 

The turns of the third roller make two triangles, one on 
the anterior surface of the chest (Fig. 64), the other upon 
the back(Fig. 65). 

After the application of the three rollers the hand and 
uncovered portion of the forearm should be supported in 
a sling suspended from the neck. 

Use. This bandage, applied completely, or some one of 
its various rollers, is employed in the treatment of frac- 
tures of the clavicle. 

Arm-and-chest Bandage. Roller Two and a Half 
Inches in Width, Seven Yards in Length. Before applying 
this bandage the arm should be placed against the side of 
the chest aud a folded towel or a pad of cotton should be 
placed in the axilla and allowed to extend from the axilla 



BANDAGES OF THE UPPER EXTREMITY. 



67 



to the elbow; the latter is used to prevent the opposing 
surfaces of skin from becoming excoriated by contact. 



Fig. 64. 



Fig. 65. 






Anterior view of turns of third roller 
of Desault's bandage. 



Posterior view of turns of third roller 
of Desault's bandage. 



The initial extremity of the bandage is placed upon the 
spine at a point opposite the elbow-joint, and it is fixed by 
a turn or two passing around the arm and chest; the ban- 
dage is then continued by making ascending spiral turns, 
covering in the arm and chest until the axilla is reached ; 
at this point the bandage is carried through the axilla of 
the sound side and over the back of the chest to the top of 
the opposite shoulder, and it is then conducted down the 
front of the arm to the elbow, is passed between the arm 



68 



BANDAGES. 



and chest and carried up the back of the arm to the 
shoulder. It is then passed obliquely across the front of 
the chest and is secured upon the back of the chest. Pins 
should be introduced at the points of crossing of the 
bandage (Fig. 66). 



Fig. 66. 





Arm-and-chest bandage. 



Use. This bandage will be found useful in fixing the 
arm to the body and in fixing the shoulder-joint where it 
is desirable to allow the forearm to be free. It is em- 
ployed in the treatment of fractures of the shaft and neck 
of the humerus to fix the arm and hold splints in position. 



BANDAGES OF THE TRUNK. 



69 



BANDAGES OF THE TEUNK. 



FrG. 67. 



Spiral Bandage of the Chest. Roller Three Inches in 
Width, Nine Yards in Length. The initial extremity of 
the roller is applied to the anterior portion of the waist, 
and fixed by one or two circular turns; the bandage is 
then carried upward, encircling the chest by ascending 
spiral turns, each turn covering in one-half of the previous 
turn until the axillary fold is reached; the roller is next 
carried around the axilla 
to the back, and obliquely 
over this to the base of the 
neck of the opposite side, 
and then it may be passed 
down over the chest and 
pinned to the spiral turns at 
several points; a pin should 
also be inserted at the point 
where the last turn of the 
roller leaves the spiral turn 
upon the back of the chest 
(Fig. 67). _ 

Use. This bandage is 
employed to hold dressings 
to the chest, and may be 
used as a temporary dress- 
ing in fractures of the ribs or sternum. Care should 
be taken that the bandage be not so tightly applied_as to 
interfere with respiration. 

Anterior Figure-of-eight Bandage of the Chest. 
Roller Two and a Half Inches in Width, Seven Yards in 
length. The initial extremity of the roller should be 
placed in the axilla of one side, and the bandage is then 
carried obliquely across the anterior portion of the chest 
to the shoulder of the opposite side; it is then carried 
backward around the shoulder and through the axilla, and 
is next conducted obliquely over the anterior portion of 
the chest to the opposite shoulder, through the axilla and 




Spiral bandage of the chest. 



70 



BANDAGES. 



again back to the anterior portion of the chest, the turns 
crossing in the median line over the sternum. These 
turns should be repeated, ascending from the shoulder 
toward the neck, each turn overlapping three-fourths of 
the preceding one, until five or six turns have been ap- 
plied, the end of the bandage being secured by a pin 
(Fig. 68), or it may be completed by a circular turn 
around the chest. 



Fig. 68. 




Anterior figufe-of-eight bandage of the chest. 



Use. This bandage may be employed to bring the shoul- 
ders forward, and to hold dressings to the anterior portion 
of the chest. 

Posterior Figure-of-eight Bandage of the Chest. 
Holler Two and a Half Inches in Width, Seven Yards in 
Length. The initial extremity of the roller should be 
placed in the axilla of the left side, and the bandage should 
then be carried obliquely across the back of the chest to 
the tip of the opposite shoulder; it is next carried through 
the axilla and conducted across the posterior portion of the 
chest to the tip of the opposite shoulder, and passed through 
the axilla to the point of starting. These turns are re- 
peated, descending from the neck toward the shoulder, until 
five or six have been applied, the end of the bandage being 
secured by a pin (Fig. 69). In applying both of these 



BANDAGES OF THE TRUNK. 



71 



bandages the crosses of the bandage, either anterior or pos- 
terior, should be made in the median line of the chest. 



Fig. 69. 




Posterior figure-of-eight bandage of the chest. 

Use. This bandage may be employed to hold dressings 
to the posterior portion of the chest and to draw the shoul- 
ders backward. 

Fig. 70. 




Suspensory and compressor bandage of the breast. 

Suspensory and Compressor Bandage of the Breast. 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. The initial extremity of the roller should be 



72 



BANDAGES. 



placed upon the scapula of the affected side, and secured 
by two oblique turns carried over the opposite shoulder 
and conducted downward under the breast to be covered 
in, and then carried to the axilla of the same side. Next 
carry the roller transversely around the chest, covering in 
the lowest portion of the affected breast. These turns 
should be repeated, the oblique turns from the axilla over 
the shoulder alternating with the transverse turns around 
the chest, until the breast is covered in, each series of turns 
ascending, and covering two-thirds of the preceding turns 
(Fig. 70). 

Fig. 71. 




/ 





Suspensory and compressor bandage of both breasts. 



BANDAGES OF THE LOWER EXTREMITY. 73 

Use. This bandage is employed to support the breast 
and to make compression at the same time; it may also be 
employed to hold dressings to the breast. 

Suspensory and Compressor Bandage of Both 
Breasts. Two Rollers Two and a Half Inches in Width, 
Seven Yards in Length. The initial extremity of the ban- 
dage should be secured by oblique turns of the axilla and 
shoulder, passing under one breast, as in the preceding 
bandage; the roller should next be carried transversely 
around the back to the other breast, then under the breast 
and upward over the opposite shoulder, then obliquely 
downward around the chest to the other side, being carried 
transversely over the lower portion of both breasts to the 
point of starting upon the back. Repeat these oblique 
turns from the shoulder to the breast and from the breast 
to the shoulder, and alternate them with a transverse 
turn around the chest and over both breasts. Both series 
of turns should ascend, and each turn should overlap 
two-thirds of the preceding one (Fig. 71). 

Use. This bandage is employed to support and com- 
press both breasts and to retain dressings to them. 



BANDAGES OF THE LOWER EXTREMITY. 

Single Spica-bandage of the Groin (Ascending). 

Roller Two and a Half Inches in Width, Seven Yards in 
length. Place the initial extremity of the bandage upon 
the anterior portion of the right thigh just below the groin, 
and secure it by one or two circular turns around the thigh, 
or place the initial extremity of the roller obliquely upon 
the upper part of the thigh and carry it behind the limb 
and upward around the outer side of the thigh to the abdo- 
men, omitting the circular turns; then carry the bandage 
obliquely across the lower part of the abdomen to a point 
just below the crest of the left ilium and conduct it trans- 
versely around the back of the pelvis to a corresponding 
point on the opposite side; then bring it obliquely down- 
ward to the groin and over to the inner portion of the thigh, 



74 BANDAGES. 

carrying it around the limb, crossing the starting-turn in 
the middle line of the thigh. These turns are repeated, 
each turn ascending and covering in two-thirds of the pre- 
vious turn, until six or eight complete turns have been 
made, and the bandage is then secured at any point where 
it ends (Fig. 72). 

Fig. 72. Fig. 73. 




1 



Descending spica-bandage of the 
Ascending spica-bandage of the groin. groin. 

Single Spica bandage of the Groin (Descending). 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. Place the initial extremity of the roller obliquely 
upon the anterior surface of the right thigh and secure it 
by one or two circular turns around the limb, or start the 
bandage with an oblique turn, as previously described; 
then carry the bandage obliquely across the abdomen to a 
point just below the crest of the ilium, and conduct it 
transversely around the back of the pelvis to a correspond- 
ing point on the opposite side; then bring it obliquely 
down over the lower portion of the abdomen, crossing the 
first turn, to the junction of the thigh with the scrotum, 
pass it under the thigh and bring it up over the lower part 
of the abdomen, and let it follow the course of the first 
turn. These turns are repeated, each turn descending and 



BANDAGES OF THE LOWER EXTREMITY. 75 

overlapping two-thirds of the previous turn until the groin 
is covered (Fig. 73). When either of these bandages is 
applied to the left groin, after the initial extremity of the 
roller is fixed, it is carried first to the crest of the ilium 
of the same side, then around the back of the pelvis to a 
corresponding point on the opposite side, then obliquely 
across the lower part of the abdomen to the outer aspect 
of the thigh, being conveyed around this and brought up 
between the thigh and the scrotum, passing obliquely over 
the groin to follow the course of the original turn. 

Double Spica-bandage of the Groins. Roller Three 
Inches in Width, Nine Yards in Length. The initial ex- 
tremity of the roller is placed upon the abdomen just 
above the the iliac crests 
and secured by one or two FlG - 74 

circular turns; the bandage 
is then carried from a point 
just below the crest of the 
right ilium obliquely across 
the lower portion of the ab- 
domen to the outer portion 
of the left thigh, is carried 
around this and brought 
up between the scrotum and 
the thigh, and is passed ob- 
liquely over the groin, cross- 
ing the previous turn in the 
median line, and is con- M 

ducted to a point just below 

the Crest of the ilium on the Double spica-bandage of the groins. 

same side. The bandage is 

then continued around the pelvis to the same point on the 
opposite side, and from this point is made to pass obliquely 
over the groin to the inner side of the right thigh, passing 
around this and coming up on its outer side, crossing the 
previous turn at the middle line of the groin, to be carried 
obliquely across the groin and lower part of the abdomen 
to the crest of the ilium on the opposite side. These turns 
are repeated, each turn covering in two-thirds of the pre- 



76 



BANDAGES. 



vious turn, until both groins have been covered (Fig. 74). 
The turns may be so applied as to ascend or descend, form- 
ing the ascending or descending double spica-bandage of 
the groins. When properly applied, this bandage presents 
three sets of crossing-turns, one in each groin and one in 
the median line of the abdomen. 

Use. The spica-bandages of the groin, either single or 
doable, are employed to hold dressings to wounds in the 
inguinal region — for instance, those resulting from herni- 
otomy, or from operations upon the glands of the groin. 
They are also employed to make pressure upon this region, 
and will often prove of use in the securing of compresses 
applied for the temporary retention of hernia?. 

Spica-bandage of Buttock. Roller Two and a Half 
Inches in Width, Seven Yards in Length. The initial ex- 
tremity of the bandage is 
FlG - 75 placed upon the back of the 

Jl v thigh just below the gluteal 

fold, and is carried around the 
thigh and brought back to the 
posterior aspect of the limb so 
as to fix and cross the starting 
turn near the middle of the 
thigh. It is next conducted 
obliquely across the thigh and 
buttocks and carried to the 
brim of the pelvis of the op- 
posite side, when it is brought 
obliquely over the abdomen 
and back to the posterior sur- 
face of the thigh. These as- 
cending turns are applied, 
each turn covering in about 
three-fourths of the preced- 
ing one, until the buttock is 
covered, and the bandage is then finished by one or two 
circular turns around the pelvis and abdomen (Fig. 75). 

Use. This bandage is employed to hold dressings to the 
upper posterior portion of the thigh, or the buttock. 






'! 




Spica-bandage of buttock. 



BANDAGES OF THE LOWER EXTREMITY. 77 

Figure-of-eight Bandage of the Knee. Roller Two 
and a Half Inches in Width, Five Yards in Length. The 
initial extremity of the roller is placed upon the right thigh 
three inches above the patella and secured by two or three 
circular turns; then conduct the bandage over the outer 
condyle of the femur across the popliteal space to the inner 
border of the tibia and around the anterior surface below 
the tubercle and head of the fibula, and make one circular 
turn ; the roller should then be carried obliquely across the 
popliteal space to the inner condyle of the femur, crossing 
the previous turn; then carry it around the front of the 

Fig. 76. 




Figure-of-eight bandage of the knee. 



thigh to the outer condyle; repeat these turns, ascending 
toward the knee from the leg and descending from the 
thigh toward the knee, and finish the bandage by a circu- 
lar turn over the patella (Fig. 76). 

This bandage may also be applied by making two circu- 
lar turns around the patella aud popliteal space, and then 
carrying the bandage to the thigh three inches above the 
patella, and then finishing it with descending turns from 
the thigh and ascending turns from the tibia, making all 
turns cross in the popliteal space. 

Use. This bandage is employed to hold dressings to the 
knee-joint either anteriorly or posteriorly. These figure- 



78 



BANDAGES. 



Fro. 77. 



of-eight turns are often employed in covering the knee in 
applying the spiral reversed bandage of the lower ex- 
tremity when it is desired that the patient be allowed to 
bend the knee. 

Figure-of-eight Bandage of Both Knees. Roller Two 
and a Half Inches in Width, Seven Yards in Length. Place 
the knees of the patient together with a compress between 
them; then place the initial extremity of the roller upon 
one thigh, about three inches above the patella, and secure 
it by one or two circular turns around both thighs; then 
conduct the roller from the outer condyle of the left femur 
obliquely across the popliteal spaces of both legs to the 

head of the fibula on the 
opposite side, making a 
circular turn around both 
legs; pass the roller from 
the head of the fibula on 
the opposite side across 
the popliteal space to the 
external condyle opposite 
the point of starting. 

Repeat these turns, de- 
scending from the thighs 
and ascending from the 
legs, until the knees are 
covered, and finish the 
bandage by carrying a 
turn of the bandage at 
right angles to the previous turns between the thighs and 
the legs (Fig. 77). 

Use. This bandage is employed to secure fixation of 
the limbs after operations upon the perineum, and may also 
be employed to obtain temporary fixation of the limbs in 
transporting cases of fracture of the femur, and after the 
reduction of dislocations of the head of that bone. 

Spica-bandage of the Foot. Roller Two and a Half 
Inches in Width, Five Yards in Length. Fix the initial 
extremity of the roller upon the ankle and secure it by 
two circular turns; then carry the bandage obliquely over 




Figure-of-eigbt bandage of both knees. 



BANDAGES OF THE LOWER EXTREMITY. 



79 



Fig. 78. 




the dorsum of the foot to the metatarsophalangeal articu- 
lation, and make a circular turn around the foot at this 
point; then continue it upward over the metatarsus by 
making two or three spiral reversed turns; next carry the 
bandage parallel with the inner or outer margin of the sole 
of the foot, according to whether it is applied to the right 
or left foot, directly across the 
posterior surface of the heel ; 
thence along the opposite border 
of the foot and over the dorsum, 
crossing the original turn in the 
median line of the foot. This 
completes the first spica turn. 
These spica turns are repeated, 
gradually ascending by allowing 
each turn to cover in three-fourths 
of the preceding turn, until the 
foot is covered in with the excep- 
tion of the posterior portion of the 
sole of the heel (Fig. 78). Care 
should be taken to see that the 
turns cross each other in the me- 
dian line and that they are kept 
parallel to each other throughout 
their course. 

Use. This bandage will be 
found very useful when it is desired to make firm com- 
pression upon the foot or to retain dressings to it ; it is 
especially useful in the treatment of sprains of the ankle 
or the anterior tarsus. 

Bandage of Foot Covering the Heel (American). 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. The initial extremity of the roller is placed upon 
the leg just above the malleoli and fixed by two circular 
turns around the leg; the bandage is then carried obliquely 
across the dorsum of the foot to the metatarso-phalangeal 
articulation, at which point a circular turn is made; two 
or three spiral or spiral reversed turns are then made, 
ascending the foot; the roller is next carried directly over 




*<<*- 



Spica-bandage of the foot. 



80 BANDAGES. 

the point of the heel and continued back to the dorsum of 
the foot; thence beneath the instep around one side of the 
heel and up over the instep; from this point it is carried 
beneath the instep around the other side of the heel and 
up in front of the ankle, from which point it may be con- 
tinued up the leg (Fig. 79). 

Use. This bandage is employed to cover in the foot, and 
retain dressings to the foot and heel. 

Fig. 79. Fig. 80. 






Bandage of foot covering the heel. Bandage of foot not covering the heel. 

Bandage of Foot Not Covering the Heel (French). 

Roller Ttvo and a Half Inches in Width, Seven Yards in 
Length. Fix the initial extremity of the roller upon the 
leg just above the malleoli and secure it by two circular 
turns around the leg; the bandage is then carried obliquely 
across the dorsum of the foot to the metatarso-phalangeal 
articulation, and at this point a circular turn should be 
made. The roller is now carried up the foot, covering it 
in with two or three spiral reversed turns, and at this 
point a figure-of-eight turn is made around the ankle and 
instep; this should be repeated once, which will cover in 



BANDAGES OF THE LOWER EXTREMITY. 81 

the foot with the exception of the heel; the bandage may 
then be continued up the leg with spiral reversed turns 
(Fig. 80). _ 

Use. This bandage may be employed to secure dressings 
to the foot, and is the one generally used to cover this part 
in applying the spiral reversed bandage of the lower 
extremity. 

Spiral Reversed Bandage of the Lower Extremity. 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. The initial extremity of the roller is placed 
upon the leg just above the malleoli and secured by 
two circular turns. It is then carried obliquely over 
the foot to the metatarso-phalangeal articulation, where 
a circular turn is made around the foot. Two or three 
spiral reversed and two figure-of-eight turns of the 
ankle and instep should be made, while just above the 
ankle one or two circular or spiral turns are made around 



Fig. 81. 



/ 



4 




Spiral reversed bandage of the lower extremity. 

the leg, and as the bandage is carried up the leg, as it 
increases in diameter, spiral reversed turns are made until 
it approaches the knee; at this point, if the limb is to be 
kept straight, the spiral reversed turns may be continued 
over this region and up upon the thigh. If the knee is 
to be bent, figure-of-eight turns may be applied until the 
knee is covered, and then the thigh may be covered with 
spiral reversed turns (Fig. 81). To cover in the thigh as 
well as the leg, two bandages of the dimensions before 
given will be required. Care should be taken to keep the 
reverses in a line and not to make them over the spine of 
the tibia, as they may thus become painful to the patient. 

6 



82 



BANDAGES. 




Use. This is one of the most frequently employed of 
the roller bandages; it is used to apply pressure to the 
lower extremity, to retain dressings, and to secure splints 
in the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Leg. Roller Two and 
a Half Inches in Width, Seven Yards in Length. This 
bandage differs from the spiral reversed bandage of the 
lower extremity only in the fact that when the swell of 
the calf is reached figure-of-eight turns are made around 

the leg instead of spiral 
FlG - 82 - reversed turns. In ap- 

plying the roller, when 
the calf of the leg is 
reached, the bandage is 
carried obliquely around 
the leg to the crest of the 
tibia and then made to 
cross the starting - turn 
in the median line; these 
descending and ascend- 
ing turns are repeated 
until the calf of the leg 
has been covered in, and 
the bandage is finished 
with one or two circular 
turns just below the knee 
(Fig. 82). 

Use. This bandage 
holds its place more 
firmly than the ordi- 
nary spiral reversed bandage of the leg, and may be em- 
ployed in the treatment of ulcers of the leg in conjunc- 
tion with strapping, where it is desirable to change the 
dressings at infrequent intervals and to allow the patient 
to walk about during the course of treatment. 



% 



m 

Figure-of-eight bandage of the leg. 



ss* 



SPECIAL BANDAGES. 



83 



SPECIAL BANDAGES. 



Fig. 83. 



Spiral Reversed Bandage of the Penis. Roller Three- 
quarters of an Inch in Width, Thirty Inches in Length. 
Fix the initial extremity of the roller by two circular 
turns around the penis close 
to the pubis; then carry the 
bandage obliquely down to 
the corona glandis; from this 
point ascend the body of the 
penis by spiral reversed turns 
to the pubis, and finish the 
bandage by two figure - of - 
eight turns around the ueck 
of the scrotum and root of the 
penis, or split the end of the 
bandage so as to form two 
tails and secure it by tying 
these around the root of the 
penis (Fig. 83). 

Recurrent Bandage of 
Stump. Roller Two and a 
Half Inches in Width, Five 
to Seven Yards in Length. 
Place the initial extremity of the roller upon the anterior 
or posterior surface of the limb a few inches above the 
extremity of the stump, and carry the bandage to the end 
of the stump, and then conduct it upward or downward 
on the limb, as the case may be, to a point directly oppo- 
site the point of starting; then bring the bandage back 
over the face of the stump to the point of starting, and 
continue these recurrent turns, each turn overlapping two- 
thirds of the previous one until the face of the stump is 
covered; then reverse the bandage and secure the recur- 
rent turns at their points of origin by two or three circular 
turns. The roller should next be carried obliquely down to 
the end of the stump, and a circular turn should be made 
around this. The bandage should then be carried up the 




Spiral reversed bandage of the penis. 



84 



BANDAGES. 



limb by spiral or spiral reversed turns beyond the point at 
which the recurrent turns terminated, and secured by one 
or two circular turns (Fig. 84). 

In applying this bandage in very short stumps resulting 
from amputations at or near the shoulder or hip-joints, 
after making the recurrent and spiral turns, it will be 



Fig. 84. 




Recurrent bandage of stump. 



found necessary to carry the bandage, in the case of the 
shoulder, across the chest to the opposite axilla and back, 
and apply several of these turns; so in case of the hip 
amputations it will be found best to finish the bandage 
with a few turns about the pelvis. 

Bandage for Securing the Hands and Feet in the 
Lithotomy Position. The hand of the patient should be 
brought down and made to grasp the outer side of the 
foot; the initial extremity of the roller is fixed by two 
circular turns around the wrist and ankle, and the bandage 
is then passed around the foot and hand, and these turns 
are alternated with turns around the wrist and ankle, until 
the hand and foot are firmly secured. The same proced- 
ure is adopted with the hand and foot of the opposite side 
(Fig. 85). 



SPECIAL BANDAGES. 



£> 



Fig. 85. 



Fig. 





Bandage for securing the hands 
and feet for lithotomy. 



Liebreich's eye-bandage. 



Liebreich's Eye-bandage. This bandage consists of 
a strip of flannel two and a half inches in width and from 
six to ten inches in length, to the extremities of which 
tapes are sewed. It may be applied transversely so as to 
cover botb eyes, or obliquely so as to cover one eye only, 
and it is secured by the tapes carried around the head 
and tied over the forehead (Fig. 86). 

Use. This bandage is used to hold compresses or dress- 
ings to the eye or eyes, and the elasticity of the flannel per- 
mits of its being applied so as to make a variable amount 
of pressure. 

Borsch's Eye-Bandage. This bandage is employed for 
holding a dressing to one eye, and consists in a strip of 
flannel, two or two and a half inches in width, which is 
passed around the head from the occiput and covers both 
eyes (Fig. 87). A narrow strip of flannel is attached to 
the posterior portion, which is carried over the head and 
passed under the horizontal strip in front of the eye which 
is to be left uncovered, and is then folded back so as to raise 
the horizontal strip from the eye, and secured (Fig. 88). 



$6 



BANDAGES. 



Fig. 87. 



Fig 





Application of Borsch's eye-bandage. 



Bandage of Scultetus. This is a compound bandage, 
consisting of a number of pieces of muslin, and may be 
prepared from a two and a half or three inch roller by 
cutting off strips long enough to encircle the part about 



Fig. 89. 




Bandage of Scultetus. 



one and one-third times. The strips are placed under the 
part iu such a mauner that the first piece shall be over- 
lapped by the second, the second by the third, and so on 



SPECIAL BANDAGES. 87 

from below upward; the pieces are then brought around 
the limb, and the extremities of the last piece are secured 
by pins (Fig. 89). This bandage was formerly much em- 
ployed in the treatment of compound fractures to secure 
dressings to the wound, and possessed the advantage that 
when a single strip became soiled it could be removed with- 
out disturbing the whole dressing, the new strip to be intro- 
duced being pinned to the extremity of the soiled piece to 
be removed, and then being drawn through by its removal. 
This bandage will often be found convenient in applying 
dressing to cases of excision of the joints, where as little 
disturbance of the parts as possible is important in dress- 
ing the wound. When the strips are attached to each 
other by a thread passed through the centre of each strip, 
the bandage is known as Pott's bandage. This bandage 
is applied and secured in the same manner, but it possesses 
no advantages over the bandage of Scultetus. 

Gauze Bandages. Bandages may be prepared from 
gauze, the same material that is used for gauze dressings, 
and are now very extensively used in surgical practice. The 
gauze bandages are prepared by cutting or tearing the ma- 
terial into strips varying in width from two inches to three 
inches, and in length from five yards to eight yards; these 
strips are then wound so as to form roller-bandages. 
Gauze bandages are sometimes employed in the dressing 
of fractures, but do not furnish as substantial a dressing 
as the ordinary muslin bandages. They, however, con- 
stitute a soft and comfortable material for holding dress- 
ings to wounds. They are applied in the same manner 
as the ordinary muslin roller, with the exception that in 
their application reverses are seldom required, as the open 
mesh of the bandage gives it considerable elasticity, so 
that the bandage can be made to adapt itself to the part 
without making reverses. Any of the ordinary bandages 
which have been previously described may be applied by 
means of the gauze bandages, such as those of the head, 
extremities, and trunk. 

In applying dressings to wounds of the head and neck 
it is often used to cover in both the head and neck, and 



88 



BANDAGES. 



also to make a few tarns over the upper part of the chest 
and around each shoulder, which prevents the turns of 
the bandage from slipping, and holds the dressing in place, 
so that it cannot be disarranged by movements of the 
patient (Fig. 90). 

Fig. 90. 




^r- — p 

Gauze bandage of head and neck. 

Flannel Bandage. These bandages are prepared from 
flannel which is cat into strips from two to four inches in 
width and from five to seven yards in length. These 
strips are formed into rollers either by hand or by means 
of the bandage- winder. Flannel bandages, by reason of 
the elasticity which they possess, can be applied without 
reverses and are used to make a moderate amount of elastic 
pressure. They are often employed in applying dressings 
to the head, especially after operations upon the eyes, and 
are generally applied as a primary roller before the appli- 
cation of the plaster-of-Paris dressings, and may also be 



SPECIAL BANDAGES. 



89 



used in subacute joint-affections, both to protect the parts 
and make a moderate amount of elastic pressure. 

The Rubber Bandage. This bandage is made from a 
strip of rubber-sheeting, from one inch to four inches in 
width and from three to five yards in length, which, for 
convenience of application, is rolled into a cylinder. 

Its use was introduced to the profession by Dr. Martin, 
of Boston, and it will be found a useful form of dressing 
where it is considered desirable to apply elastic pressure to 
a part (Fig. 91). 

It may be employed in the treatment of varicose veins 
of the legs, in chronic ulcers of those parts where pressure 
is an important element in the treatment, and may be used 
as a substitute for strapping to secure this object. Its ap- 



Fig. 91. 




Martin's rubber bandage. 



plication has also been recommended in the treatment of 
swelled testicle in that stage of the affection in which 
pressure is indicated. 

For application to the leg a rubber bandage two and a 
half inches in width and three yards in length is required. 

The initial extremity of the roller is fixed upon the foot 
near the toes and secured by a circular turn ; the foot is 
then covered in by spiral turns overlapping each other 
about two-thirds, and a figure-of-eight turn is made from 
the ankle to the instep. The bandage is then carried up 
the limb to the knee with spiral turns, where it is secured 
by two tapes sewed to the terminal extremity of the ban- 
dage, which are passed around the leg and tied. The 



90 BANDAGES. 

bandage need not be reversed, as its elasticity allows it to 
conform to the shape of the limb. Care should be taken 
not to apply the turns with too much firmness; the ban- 
dage should be stretched very slightly; if this precaution 
is not taken, it soon becomes uncomfortable to the patient. 
A patient using one of these bandages will soon learn to 
apply it himself, making just the requisite amount of ten- 
sion to secure its holding its place, and to insure a com- 
fortable amount of pressure upon the part. A well-fitting 
stocking may be placed upon the limb before the bandage 
is applied, or it may be applied directly to the skin. 

The bandage should be removed at night when the 
patient goes to bed and hung up to dry, as its inner sur- 
face becomes moist from the secretions from the skin; it 
should be reapplied as soon as the patient rises in the 
morning. 

In using it in the treatment of ulcers of the leg no oint- 
ment should be applied to the ulcer, as oily dressings soon 
destroy the rubber; applications may be made to the ulcer 
by means of dry powders, such as oxide of zinc, iodoform, 
or aristol, before the bandage is applied. 

In the treatment of swelled testicle the bandage is ap- 
plied to the testicle by means of recurrent turns not too 
firmly made, and secured in place by spiral turns, until the 
whole surface of the organ is covered in; the end of the 
bandage is secured with tapes tied around the root of the 
scrotum. The same precaution to apply the bandage so 
as to make only moderate pressure should also be observed 
here. 

Elastic- webbing Bandage. This bandage, which is 
woven from threads of rubber covered with cotton or silk, 
has recently been introduced, and possesses all the advan- 
tages of the rubber bandage as regards elasticity, and has 
the additional advantage that the air can circulate through 
the meshes of the bandage and moisture cau evaporate from 
the surface covered by the bandage, so that the skin cov- 
ered by it does not become bathed in perspiration, as is 
the case with the rubber bandage. It is applied in the 
same manner and for the same purposes as the rubber ban- 



FIXED DRESSINGS, OB HARDENING BANDAGES. 91 

dage. In the treatment of varicose veins we have found 
it a most satisfactory dressing, as the patient soon learns 
to apply it himself, so as to make the requisite amount of 
pressure 



FIXED DRESSINGS, OR HARDENING BANDAGES. 

For the application of these dressings a variety of 
substances are used which are incorported in the meshes 
of some fabric, such as crinoline or cheese-cloth, or painted 
over its surface to give fixity or solidity to the bandage. 

The materials most commonly used in the preparation 
of fixed dressings are plaster-of-Paris, starch, silicate of 
sodium or potassium, and paraffin. 

Plaster-of Paris Dressings. 

The plaster-of-Paris used for the application of surgical 
dressings should be of the same quality as that which the 
dental surgeons employ in taking casts for teeth — that is, 
the extra calcined variety. * If moist or of inferior quality, 
it will not set rapidly or firmly, and will fail to give suffi- 
cient fixation to the dressing. 

Methods of Applying the Plaster-of-Paris Dressings. 
The plaster-of-Paris dressing may be applied in several 
ways, either by covering the part to be enclosed with some 
loose fabric, and rubbing the moist plaster into it, alter- 
nating the layers of the fabric with layers of moist plaster, 
or it may be applied by means of a roller which has been 
prepared by incorporating plaster-of-Paris in its meshes. 

It may also be applied in the form of the Bavarian 
dressing (page 99), or in the form of moulded plaster-of- 
Paris splints (page 100). 

To apply a plaster-of-Paris dressing according to the first 
method, the part to be enclosed — the leg, for instance — 
should first be covered by a neatly applied flannel bandage, 
or a muslin bandage which has been shrunken by being 
washed; new muslin is not satisfactory as a primary appli- 



92 BANDAGES. 

cation to a limb in applying a plaster-of -Paris dressing, as 
the moisture from the plaster wets it and causes it to 
shrink, so that it may exert injurious pressure after the 
bandage becomes dry. 

The limb having been covered by the bandage, and 
any bony prominences, such as the malleoli, having been 
padded with small wads of cotton to prevent undue press- 
ure upon them, the part is next covered by a layer of turns 
of a crinoline bandage or by strips of cheese-cloth or any 
other loose material. A small quantity of plaster-of -Paris 
is next mixed with water until it has the consistence of 
thick cream, when it is smeared evenly over the whole sur- 
face of the previously-applied bandage. Another layer of 
the bandage or of strips is next applied, and the plaster is 
smeared over this in the same manner, and so alternate 
layers of plaster-of- Paris and bandage are applied until a 
casing of the desired thickness is obtained. If the plaster- 
of- Paris of the quality previously described be used, it will 
set or become hard in a few minutes. 

The most convenient method of applying the plaster-of - 
Paris dressing is that introduced by Prof. Sayre, which 
consists in the use of bandages which have been previously 
prepared with plaster-of -Paris; these are moistened and 
applied while moist to the part to be encased. 

Preparation of the Plaster-of-Paris Bandage. These 
bandages are prepared by taking cheese-cloth, mosquito- 
netting, or crinoline, which latter is by far the best fabric, 
and cutting or tearing it into strips two and a half to three 
inches in width and five yards in length. These are laid 
on a table, and plaster-of-Paris of the quality before men- 
tioned is dusted over them and rubbed into the meshes of 
the fabric; the material when impregnated with plaster is 
loosely rolled into a cylinder, and these bandages when 
prepared should be placed in air-tight jars or tin cans until 
required. 

Bandages thus prepared, which have been exposed to 
the air or have been kept for a long time, are not apt to 
set well when applied; but if such bandages are placed in 
a hot oven and baked for half an hour before being used, 



FIXED DRESSINGS, OR HARDENING BANDAGES. 93 

they will be found to set as satisfactorily as those freshly 
prepared. 

These bandages may be prepared by a machine made for 
this purpose, but I do not think that they are apt to have 
the plaster as evenly distributed through them, and, there- 
fore, are not as satisfactory as those prepared by hand. 

Application of the Plaster-of-Paris Bandage. Before 
applying this dressing, the part to be encased — the leg, for 
iustance — should be covered by a flannel roller, the bony 
prominences being protected by pads of cotton, or a closely 
fitting stocking may be applied to the part. 

The bandage should be dipped in warm water and kept 
covered for a few minutes; it may be squeezed with the 
hand, and as soon as bubbles of air cease to escape it is a 
sign that it is thoroughly soaked and is ready for applica- 
tion. 

Fig. 92. 





v.>jhl 



Leg encased in plaster-of-Paris dressing. 



On removing it from the water the excess of water 
should be squeezed out by the hand, and the bandage 
should theu be evenly applied to the limb with just enough 
firmness to make it fit the part nicely, and as few reverses 
as possible should be made. A sufficient number of ban- 
dages are applied to make a dressing as firm as may be 
required; three rollers of the above dimensions are usually 
quite ample for a dressing for the leg, and when the last 
roller has been applied some dry plaster should be moist- 
ened with water until it has the consistency of thick 



94 BANDAGES. 

cream, and rubbed evenly over the surface of the bandage 
to give it a finish (Fig. 92). If a good quality of plaster 
has been used the bandage should be quite firm in from 
ten to fifteen minutes, but the patient should not for a few 
hours be allowed to put any weight upon the bandage. 

An equally firm bandage may be applied with the use 
of a less number of bandages, if the surgeon rubs over 
the surface of each layer of bandage applied a little moist 
plaster, then applying another layer and repeating the 
same procedure; finishing the dressing by an external 
coating of moist plaster, as above described. 

In applying these dressings a fewer number of bandages 
will be required if narrow strips of tin, zinc, or binder's 
board are incorporated in the layers of the bandage, wdiich 
also increase the strength of the dressing. 

Application of the Plaster- of-Paris Bandage to the 
Thigh and Pelvis. Where it is desirable to apply a 
plaster-of-Paris bandage to the thigh, and at the same time 

Fig. 93. 




Pelvic supporter. 

fix the hip-joint by including the pelvis in the bandage, 
the use of a pelvic supporter (Fig. 93) is most satisfactory. 
The patient is placed upon the supporter so that the lum- 
bar spine rests upon the body of the supporter, while the 
pelvis rests upon the metal shelf which extends from it, 
as seen in Fig. 94. The limb is extended and held in the 
required position, and the plaster bandage is applied to the 
thigh and is also carried around the pelvis, and passed over 



FIXED DRESSINGS, OB HARDENING BANDAGES. 95 

the metal shelf upon which the pelvis rests. When the 
bandage has become firm, the supporter is removed by 
slipping it upward. 

Fig. 94. 




Position of patient upon pelvic supporter. 

Interrupted Plaster- of-Paris Dressing. This form of 
plaster-of-Paris dressing is applied by first placing a short 
iron rod under the extremity, opposite to and extending 
some distance above and below the point at which the 

Fig. 95. 




Interrupted plaster-of-Paris dressing. (Stimson.) 



dressing is to be interrupted ; this is fixed by a few turns 
of the plaster bandage above and below the portion of 
the limb which is to be left exposed; stout wire is next 
bent into loops, the extremities of which are incorporated 
in the subsequent turns of the plaster bandage ; three 



96 BANDAGES. 

loops thus placed in addition to the posterior iron bar 
will usually make the dressing sufficiently firm (Fig. 95). 
A number of turns of the bandage are applied to firmly 
fix the loops, and the limb is held in the desired position 
until the plaster has set. 

Application of the Plaster-of-Paris Jacket. The 
patient's body should be covered with a soft, closely 
fitting woven shirt without arms, but with shoulder-straps 
to hold it in position, or an ordinary woven undershirt may 
be employed; one or two folded towels, or a pad of cotton 
wrapped in a towel, are next placed over the abdomen be- 
tween the shirt and the skin — this is called, by Prof. Sayre, 
the dinner pad, and is intended to leave space for the dis- 
tention of the abdomen after eating. Small pads of raw 
cotton may also be placed over the anterior iliac spines, 
and, in the case of females, a pad of cotton wrapped in a 
handkerchief may be placed over each mammary gland. 

The patient should next be suspended by the apparatus 
consisting of a collar and arm-pieces attached to a cross- 
bar (Fig. 96), which is attached by a cord and pulley to a 
tripod. If this apparatus is not at hand, a very satisfac- 
tory substitute may be made by folding two towels into 
cravats and tying together the ends, so as to make two 
loops, one of which is placed in each axilla; a bar of wood 
two and a half feet in length is next taken and the loops 
are secured to the ends of this by stout cords or handker- 
chiefs; a Barton's bandage is next applied to the head, and 
a strip of bandage is passed under the turns which cross 
the vertex and is secured to the middle of the cross-bar. 
The bar is next suspended by a cord passed through a 
pulley or ring, which may be attached to the sill of a door 
if the ordinary tripod cannot be obtained. 

The patient should be slowly raised by the apparatus 
until the toes only are in contact with the floor, and the ex- 
tension should not be carried to the point which makes it 
uncomfortable to the patient (Fig. 97). The shirt should 
be drawn downward over the hips by an assistant and held 
in place until a few turns of the bandage have been applied. 
^The plaster bandage having been soaked and squeezed, 



FIXED DRESSINGS, OR HARDENING BANDAGES. 97 

a turn should be made around the body above the pelvis, 
and it should then be carried downward below the iliac 
spines, and from this point made to ascend gradually 
by spiral turns until it reaches the axillary line. The 
turns should be applied smoothly and not too tightly. 
After two or three layers of turns have been applied, the 



Fig. 96. 



Fig. 97. 




Suspensory apparatus. 



Patient suspended for application ot 
plaster jacket. 



surgeon may rub some moist plaster upon their surface if 
he desires to use fewer bandages. These turns are repeated 
until a bandage of the desired thickness is applied, and the 
surface of the dressing may be finished by rubbing it over 
with moistened plaster. This jacket for a child will gen- 

7 



98 



BANDAGES. 



Fig. 98. 



erally require the use of three or four bandages of the 
dimensions given; for an adult, from six to eight bandages. 
The patient should be kept suspended until the bandage 
has set usually from ten to fifteen minutes, and then should 
be carefully lifted so as not to bend the spine, and placed 
on his back upon a mattress, until the dressing becomes 
perfectly hardened. The dinner pad and mammary pads, 
if they have been used, should next be removed. In 
applying this dressing, strips of zinc or tin may be placed 
between the layers of bandage if it is desired to give more 
strength to the jacket. 

Application of the Jury-mast by Means of Plaster- 
of- Paris. In disease of the spine involving the cervical 
or upper dorsal region the ordinary plaster-of-Paris jacket 
is not satisfactory, and in such 
cases the " jury-mast" is employed 
in connection with the plaster 
jacket. In applying the " jury- 
mast" the same steps are taken in 
the preparation of the patient as 
in applying the plaster-of-Paris 
jacket, with the exception of ex- 
tension, which need not be used. 

After three or four layers of the 
plaster bandage have been applied 
to the body, an apparatus made of 
two bars of metal having two per- 
forated strips of zinc attached to 
them a few inches apart, which 
partly encircle the body, is applied 
and held in position by turns of 
the plaster bandage. The perpen- 
dicular bars have at their upper 
part a slot, into which the lower 
end of the "jury-mast" fits, and 
is secured by a screw; to the upper 
part of this is attached a movable 
cross-bar, to which are fastened the straps of the collar 
from which the head is suspended (Fig. 98). 




Head-support and jury-mast. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 99 

The Bavarian Dressing. To apply this dressing, which 
is sometimes employed in the treatment of fractures of the 
extremities, take two pieces of Canton flannel the length of 
the part to be enclosed, and more than wide enough to 
envelope its circumference. In applying it to the leg these 
pieces should be cut so as to correspond to the outline of 
the leg and posterior portion of the foot. 

These pieces should be placed one over the other and 
sewed together in the middle line, the seam corresponding 
to the back of the leg. The leg and foot are then placed 
upon this, and the inner layer of flannel is brought up in 
front of the leg and over the dorsum of the foot and made 
fast with pins or a few stitches (Fig. 99). Plaster-of- Paris 

Fig. 99. 




Bavarian dressing. 



is Dext mixed with water to form a paste, which is rubbed 
thickly and evenly over the flannel next to the limb until 
a sufficient thickness is obtained; the outer layer of flannel 
is then brought up about the leg and moulded to its sur- 
face by the hands. A loosely applied roller may now be 
used to hold the dressing in place until the plaster has set. 
When it is necessary to inspect the parts, the turns of 
the bandage are cut, and upon separating the layers of 
flannel the two halves can be turned aside, the seam at the 
back acting as a hinge. Upon reapplying the splints to 



100 BANDAGES. 

the leg they may be retained in position by a roller or by 
one or two strips of bandage. 

Moulded Plaster Splints. It is sometimes found diffi- 
cult to apply the ordinary plaster dressings to parts irreg- 
ular in their shape, and at the same time to have a splint 
which can be removed with ease. To accomplish this pur- 
pose moulded splints of plaster may be made by cutting a 
paper pattern of the part to be covered in, and then cutting 
pieces of crinoline to conform to this pattern; eight or ten 
pieces will usually form a splint of sufficient thickness. 
One of these pieces of crinoline is laid upon a table and 
dry plaster is rubbed into its meshes ; another is laid 
upon this and plaster is applied to it in the same way, 
and so on until all the pieces have been placed in posi- 
tion, one over the other, with plaster rubbed well into 
the meshes. The dressing is then folded up and dipped 
into water, squeezed out, and moulded to the part and held 
in position, until it sets, by the turns of a bandage. The 
edges should overlap slightly, and in applying it a strip of 
waxed paper may be placed under the overlapping edge to 
prevent its adhesion to the dressing below, and thus facili- 
tate its removal. Splints prepared in this way can be 
removed with ease, and are often of service in cases where 
it is desirable to inspect the parts frequently; I have em- 
ployed with advantage such splints in making fixation of 
the hip-joint in cases of coxalgia, and also for the same 
purpose in affections of other joints. The splints upon 
being reapplied are secured by a few strips of bandage, or 
by a roller bandage. 

Trapping Plaster-of-Paris Bandages. In applying 
the plaster-of-Paris dressing to a part where there is a 
wound which is covered by the plaster bandage, it is well 
to make some provision whereby the plaster dressing over 
the site of the wound may be cut away, making a trap or 
window through which the wound may be inspected or 
dressed, if necessary (Fig. 100). To accomplish this, be- 
fore applying the plaster bandage, a compress of lint or 
gauze or a small pasteboard box should be placed over 
the wound, which, when the dressing is completed, forms 



FIXED DRESSINGS, OB HARDENING BANDAGES. 101 

a projection on its surface, indicating the position of the 
wound, and also allows the surgeon to cut away the dress- 
ing without injuring the skin below. These traps may be 
cut out after the bandage has partially set, or after it has 
become hard. In applying the plaster-of- Paris dressing 

Fig. 100. 




Plaster-of-Paris bandage trapped. (Esmakch.) 

in cases of compound fracture and after osteotomy, I 
always make provision for trapping of the bandage if it 
should become necessary, although in the vast majority of 
cases if the wound remain aseptic it does not have to be 
done. 

Removing Plaster-of-Paris from the Hands. One 
objection to the use of plaster-of-Paris dressings is the 
difficulty of removing it from the hands of the surgeon, 
and the harsh condition in which the skin is left after its 
removal. If, however, the hands are washed in a solution 
of carbonate of sodium — a tablespoonful to a basin of 
water — the plaster will be readily removed and the skin 
will be left in a soft and comfortable condition. Eubbing 
the hands with moist brown sugar or cornmeal accom- 
plishes the same object. 

Removal of the Plaster-of-Paris Bandage. The re- 
moval of the plaster-bandage is sometimes a matter of 
difficulty, particularly if it has to be removed before the 
parts below it are consolidated, as it may disarrange them 



102 



BANDAGES. 



and cause the patient pain if it is not accomplished with- 
out much force. 

When the bandage is applied to get a cast of a part, or 
in the treatment of fractures where it may be necessary to 
remove the bandage in a few days to inspect the parts, a 
strip of sheet-lead one-half of an inch in width is first placed 
over the flannel bandage and is allowed to project at each 
end beyond the dressing; the plaster can then be readily 
cut through upon the strip with a knife without injury to 
the parts below (Fig. 101). As soon as the bandage has 
become firm the lead strip is removed by traction upon 
one end of it, and if the bandage has been entirely divided 
it can be removed at any time without difftcultv. 



Fig. 101. 




Cutting plaster bandage upon lead strip. 



In applying plaster dressings to the extremities, even if 
their removal is not likely to be immediately required, I 
usually employ the lead strip, catting the bandage upon 
it, but leaving three or four bridges of undivided bandage, 
which can be easily divided when the removal of the ban- 
dage is finally required. 



FIXED DRESSINGS, OB HARDENING BAND A GES. 103 

They may also be removed by means of a saw devised for 
this purpose (Fig. 102), or by strong cutting-shears of vari- 
ous kinds (Fig. 103); or a line may be painted over the 



Hunter's saw for removing plaster-bandages. 

dressing with hydrochloric acid or vinegar, which softens 
the plaster so that it can readily be cut through with a 
knife. The incision of the bandage upon the lead strip or 

Fig. 103. 




Shears for cutting plaster bandages. 

the use of the saw or shears is, I think, most satisfactory in 
removing these dressings. They should be used carefully, 
as the final layers of the bandage are divided, to avoid 
wounding the skin. 

Uses of Plaster-of-Paris Dressings. These dressings 
are employed to secure fixation as primary or secondary 
dressings in the treatment of fractures, and in the ambu- 
lant treatment of fractures, and for a like purpose in inju- 
ries and diseases of the joints. They are also largely used 
in the treatment of diseases and deformities of the spinal 
column, and will be found most satisfactory applications 
after osteotomy and tenotomy, to secure immobility and 
hold parts in their corrected positions; when employed 
in the dressing of cases after tenotomy, they are generally 
used for a few weeks until the proper mechanical appa- 
ratus is applied. 



104 BANDAGES. 

The Starched Bandage. To apply this bandage starch 
is first mixed with cold water until a thin, creamy mixture 
results, and this is heated until a clear mucilaginous liquid 
is produced. The part to be dressed is first covered with 
a flannel-roller, and over this a few layers of a cheese-cloth 
or crinoline bandage, which has been shrunken, are applied; 
the starch is then smeared or rubbed with the hand evenly 
into the meshes of the material, and the part is again cov- 
ered with a layer of turns of the bandage, and the starch 
is again applied; this manipulation is continued until a 
dressing of the desired thickness is produced. Strips of 
pasteboard may be applied between the layers of the ban- 
dage to give additional strength to the dressing, if desired. 

It requires from twenty-four to thirty-six hours for the 
starched bandage to become dry and thoroughly set. It 
may be removed in the same way in which the plaster-of- 
Paris dressing is removed. 

Use. Before the introduction of the plaster-of -Paris 
dressing it was frequently employed in the treatment of 
fractures, and in injuries and diseases of the joints. It 
may be used in such cases, but possesses no advantage 
over the former dressing, and has the disadvantage of set- 
ting much less promptly. 

Silicate of Potassium or Sodium Bandage. In ap- 
plying this bandage, after a flannel-roller and several 
layers of a cheese-cloth or crinoline bandage have been 
applied to the part, the surface of the latter is coated with 
silicate of sodium or potassium applied by means of a 
brush, then a second layer of bandage is applied and 
treated in the same manner, and this manipulation is con- 
tinued until a bandage of the desired thickness is produced. 
This dressing may also be applied by soaking loosely wound 
rollers of crinoline in silicate of potassium or sodium and 
applying them to the part as the plaster-of-Paris bandage 
is applied. It requires twenty-four hours for this dressing 
to become firm. As it is irksome for a patient to keep 
a part quiet while the silicate bandage is becoming firm, 
I often cover it as soon as applied with a layer of tissue- 
paper, and apply over it a light plaster-of-Paris bandage, 



FIXED DRESSINGS, OR HARDENING BANDAGES. 105 

which sets in a few minutes; this is removed at the end of 
twenty-four hours, when the silicate bandage is usually 
firm. In removing the silicate bandage it may be first 
softened by soaking it in warm water, and then it can be 
readily cut with scissors, or it may be cut with bandage 
shears. 

In applying either the starched bandage or the silicate 
of potassium bandage care should be taken to use cheese- 
cloth or crinoline which has been shrunken by being 
moistened and allowed to dry before being employed; 
otherwise dangerous compression of the part may occur if 
the bandage has been firmly applied and shrinks after its 
application. 

The Paraffin Bandage. Paraffin, which melts at from 
105° to 120° F., is used in the application of this ban- 
dage. The limb being covered by a flannel roller, a vessel 
containing paraffin is placed in a basin of boiling water. 
As the roller, which may be either of flannel, cheese-cloth, 
or crinoline, is unwound it is passed through the melted 
paraffin and applied to the part, and the turns are repeated 
until a dressing of sufficient thickness results, when the 
surface may be brushed over with melted paraffin. This 
dressing sets very rapidly, being quite firm in from five 
to ten minutes. 

Moulded Splints. 

Raw-hide or Leather Splints. In moulding raw- 
hide or leather splints it is necessary, first, to apply a 
plaster-of- Paris bandage to the part to which the raw- 
hide splint is to be fitted; and as soon as the plaster 
has set it is removed, and a solid plaster cast is next 
made by pouring liquid plaster-of-Paris into this mould. 
When this has become dry a piece of raw-hide, which 
has been soaked for a time in warm water, is moulded 
to the cast and held firmly in contact with it by tacks 
or a bandage until it has become perfectly dry. It is 
then removed, and its surface is covered with several 
coats of shellac, to prevent its absorbing moisture from 



106 



BANDAGES. 



Fig. 104. 



the skin when applied, and changing its shape. Eyelets 
or hooks are fastened to the edges of the splint, through 
which tapes are passed to secure the splint in place. 

Made in this manner raw-hide splints fit the part very 
accurately, and constitute a very satisfactory dressing for 
cases of joint-disease, and in the form of leather jackets 
are often employed in the treatment of disease of the spine 
in place of the plaster-of-Paris jacket (Fig. 104). 

In the treatment of high dorsal or cervical caries a 
leather splint in two sections, which 
rests upon the shoulders and sup- 
ports the head, is often used with 
good results (Fig. 105). 

Binder's Board or Pasteboard 
Splints. This material, which can 
be obtained in sheets of different 
thickness, is frequently employed 
for the manufacture of splints. In 
moulding these splints a portion of 
the board of the requisite size and 

Fig. 105. 





Leather jacket with jury- 
mast. 



Leather splint for cervical caries. 
(Owen.) 



thickness is dipped in boiling water for a short time, and 
when it has become softened it is removed and allowed to 
cool; a thick layer of cotton batting is next applied over 
it, and it is then moulded to the part and held firmly in 



FIXED DRESSINGS, OB HARDENING BANDAGES. 107 

place by the turns of a roller bandage; in a few hours it 
becomes dry and hard. 

This material from its cheapness and the ease with which 
it is obtained, is frequently employed to mould splints for 
the treatment of fractures, especially in children, and for 
the fixation of joints in the treatment of acute and chronic 
joint affections. A moulded pasteboard splint may also 
be employed to fix the ends of the bones after the excision 
of a joint. 

Porous Felt Splints. This material is also employed 
for the manufacture of splints, and is applied by dipping 
the material in hot water and then moulding it to the part 
and securing it by a bandage; as it dries it becomes hard. 

Hatters '-felt Splints. Hatters' -felt may also be em- 
ployed for the manufacture of splints or dressings. It is 
softened by dipping it in boiling water or heating it in the 
flame of an alcohol lamp, and when soft and pliable it is 
moulded to the part, and as it cools it again becomes hard. 
These splints are employed for the same purpose as those 
made of plaster-of-Paris, leather, or pasteboard. 






PART II. 

MINOR SURGERY 



SURGICAL BACTERIOLOGY. 

Bacteria (Schizomycetes). These are minute cellular 
organisms of microscopic size, classified as belonging to 
the vegetable kingdom, among the fungi. They play an 
active part in the causation of the processes of fermenta- 
tion and putrefaction, and are the causal agents of many 
varieties of diseases. The word germ is often used as 
synonymous with bacterium in speaking of the organisms 
that cause disease, but we must remember that certain 
pathogenic germs, as the hcematozoon malaria?, the amoeba 
coll, and the coccldcea, are members of the animal king- 
dom and are not bacteria. 

Bacteria may be divided into the lower and the higher 
bacteria. The lower forms are always unicellular, 
although in the process of growth cells may remain 
attached to each other; while the higher forms are fila- 
mentous, often branched, are made up of numbers of 
simple cells joined together, and the cells sometimes show 
a tendency to specialization. To this class belongs the 
organism which causes actinomycosis, the Actinomyces 
bovis seu hominis, and also the streptothrix madura?, the 
organism of Madura foot or mycetoma. The lower bac- 
teria, with which we are mainly concerned, are unicellular, 
exceedingly minute, the round forms measuring not more 
than 1 micromillimetre (-2 5-^0 "0 mcn ) m diameter, and, 
therefore, only capable of investigation under the highest 



SURGICAL BACTERIOLOGY. 109 

powers of the microscope. When unstained they appear 
to be homogeneous, but by staining can be seen to possess 
a cell-wall or limiting membrane, not always well defined, 
called the ectoderm, enclosing the protoplasmic contents or 
endoderm, which contains no nucleus. The cell-wall is 
probably of a gelatinous nature, and when it is well de- 
fined the bacteria are said to be capsulated. In the proto- 
plasm of the cell body certain bodies, metachromic granules, 
are sometimes seen by staining, as well as other round or 
oval unstained spaces, which, when situated at the ends of 
a bacillus, are known as polar granules. Both of these 
are probably either the results of degenerative changes, 
or are artificially produced in drying. 

Certain bacteria produce coloring matters — red, yellow, 
and blue — many of which are allied to the lipochromes, a 
class of coloring matters found in certain animal and vege- 
table organisms. 

Unicellular bacteria are classified according to their 
shape into cocci, or round cells, bacilli, or rod-shaped 
cells, and spirilla, which are cylindrical cells of curved or 
spiral outline. Motility in those bacteria which possess 
it is due to the presence of cilia or flagella. The ordinary 
mode of growth of bacteria is by division or splitting. 
Under circumstances unfavorable to growth they may also 
produce spores, but not as a means of multiplication, as one 
bacterium usually produces but one spore. 

Spores. These may be of endogenous or arthrogenous 
origin. Endogenous spores arise especially in the bacilli. 
They appear in the protoplasm of the cell as granules, 
which develop into round, oval, or short rod-shaped 
bodies; the remaining portion of the bacterium either 
persisting for a time or disappearing very soon. Arthro- 
genous spores appear to be cocci which have swollen, 
become more refractive, and are more resistant to un- 
favorable surroundings than the original coccus. Spores 
are highly refractive, and consist of a protoplasmic body 
with a dense surrounding membrane. They are very resist- 
ant to unfavorable surroundings, and are much more diffi- 
cult to destroy by heat, chemical reagents, or drying than 



1 1 MINOR S UR GER Y. 

are adult bacteria. When placed under circumstances 
favorable to their growth, the capsule splits, a little bud 
appears and develops into an adult bacterium. 

The ordinary method of multiplication of bacteria is by 
division or fission, one individual dividing into two, and 
these again into two more, the process sometimes taking 
place with great rapidity. The new cells may remain 
attached or separate, according to the nature of their 
limiting membrane. In the case of cocci, when forming 
pairs, they are called diplococci. They may alto be tetra- 
genous, or form chains, as in the streptococci and strepto- 
bacilli, or bunches, as in the case of the staphylococci. 
A zooglea mass is formed by the cohesion of a large num- 
ber of bacteria, where, owing to the gelatinous nature of 
their envelopes, they adhere to each other and appear to 
be embedded in jelly. 

Bacteria are found widely distributed in the air, the 
water, the earth, and wherever there is organic substance 
from which they can obtain their nutrition. They live 
by breaking up into simpler forms the complex organic 
compounds on which they are dependent for their carbon 
and nitrogen, being unable to extract the same from inor- 
ganic material. They also require moisture, being de- 
stroyed in time by drying. Those which require oxygen 
are called aerobic, while those which only grow when it is 
excluded are called anaerobic. Facultative aerobic and 
facultative anaerobic are terms used to designate those bac- 
teria which can grow in its presence or absence; the first, 
however, growing best with and the latter best without it. 
Another division of bacteria is into saphrophytic, or those 
living on dead organic matter, and parasitic, or those de- 
pending on living organisms, the latter embracing the 
pathogenic bacteria. The boundary line between these 
two classes is not well defined, however. A certain 
amount of heat is necessary to bacterial existence, the 
pathogenic germs growing best at the body temperature; 
they are destroyed by high temperatures, most of the 
pathogenic bacteria being killed between 122° and 140° 
F. (50° and 60° C). The spores are, as a rule, much 



SURGICAL BACTERIOLOGY. HI 

more resistant to heat. Low temperatures tend to inhibit 
the growth of bacteria rather than to destroy their life. 
Direct sunlight also has an injurious action upon them. 

Cultivation. Bacteria are studied outside of the body 
by growing them on culture-media, which may be liquid or 
solid, proteid or carbohydrate-containing material. The 
media are sterilized and kept in tubes or dishes (Petri's 
dishes). A little of the culture or material to be studied is 
transferred to the culture medium by a sterilized platinum 
wire called an ose, and spread on the surface of the solid 
medium (stroke-culture), or plunged into it (stab-culture), or 
mixed with the fluid medium. The tubes or plates are then 
placed in an oven heated to the required temperature. The 
germs form colonies of characteristic size, shape, and color- 
ing, and the different species may thus be isolated and 
studied. The liquid media include bouillon, peptone solu- 
tion, and extracts of vegetable substances, as potato. Solid 
media include mixtures of beef extracts with gelatin or 
agar-agar, coagulated blood-serum, and slices of potato or 
other vegetables. 

Inoculation. The action of bacteria and their toxins 
is studied experimentally by the injection of cultures, or 
of the body fluids or the juice of bacterially infected tis- 
sues into some of the lower animals. The animals usually 
employed are the guinea-pig, rabbit, mouse, rat, and 
pigeon. Injections are made with a sterile hypodermic 
syringe under the skin, into the peritoneal cavity, intra- 
venously, and into the anterior chamber of the eye, or the 
skin may be merely scarified. The animal is carefully 
watched afterward, its symptoms noted, and when dead of 
the disease, or killed, cultures are made from the organs, 
and the tissue-changes studied. 

Staining. In order to detect bacteria in the tissues, or 
to study and differentiate them from each other, it is neces- 
sary to stain them, and this is accomplished by the use of 
dilute aqueous or alcoholic solutions of the aniline dyes, 
counter-staining the tissues to make their detection easier. 
Bacteria differ widely in the facility with which they take 
the stains, some staining readily, while others require the 



112 MINOR SURGERY. 

action of heat or of a mordant; and they differ also in the 
tenacity with which they retain the stains in the presence 
of various reagents, as alcohol and the mineral acids. We 
are thus able to separate different bacteria by the use of 
special methods of staining and decolorizing. For exam- 
ple, the gonococcus, the bacillus coli communis, and the 
typhoid bacillus, are decolorized by the use of Gram's 
method; while the bacilli of anthrax, tuberculosis, diph- 
theria, and tetanus are stained by it. The aniline stains 
most frequently employed are methylene-blue, gentian- 
violet, thionin, fuchsin, dahlia, and vesuvin. 

Koch's Law. To prove that a certain bacterium is the 
cause of a disease, the following rules have been laid down 
by Koch: The bacterium must first be found in the diseased 
person or animal. It must be cultivated outside of the 
body. When inoculated in pure culture in a healthy ani- 
mal, it must produce the original disease. From the body 
of the animal the original microbe must again be isolated. 

Intoxication and Infection. Bacteria usually gain an 
entrance into the body through some break in the contin- 
uity of the skin or mucous membrane, especially the latter, 
owing to its being easier of penetration. They often enter 
through an open wound. Favoring elements are a weak- 
ened or diseased state of health of the individual, or an 
unusual virulence of the germ. If the germs remain 
localized, and only their products are absorbed, the pro- 
cess is spoken of as intoxication. If the germs themselves 
enter the circulation, we have infection, although the term 
infection is also used by surgeons to denote the presence 
of bacteria in a wound, without necessarily or even usually 
implying their presence in the circulation. If the germ 
be pyogenic — that is, one that excites suppuration, the 
symptoms produced by the absorption of its products con- 
stitute saprcemia. If the germ enters the circulation we 
have septicemia, and if it finds lodgement in the tissues 
or organs and gives rise to secondary abscesses, we have 
pycemia. 

Elimination. Bacteria are eliminated by the kidneys, 
the intestine, the salivary glands, in the bile and milk, and 



SURGICAL BACTERIOLOGY. 113 

probably also by the sweat-glands. They frequently cause 
lesions in the eliminating organ. 

Pathogenic Action. The pathogenic action of bacteria 
is due to the formation of certain poisonous products 
secreted by them, or produced by their action upon the 
tissues. From the bacteria themselves, by their degen- 
eration, we have also formed the proteins. The bacteria by 
their secretion produce the ferments, and, perhaps, the 
toxins ; and by their action upon the tissues we have pro- 
duced the 'ptomaines, amines, peptones, albumoses, fatty 
acids, etc. 

Toxins. The toxins are produced by the pathogenic 
bacteria. They are poisonous when injected, even in very 
minute doses, acting after a period of incubation, and are 
looked upon by many observers as being of the nature of 
ferments. Others have classified them as toxalbumins or 
toxalbumoses. The different pathogenic bacteria elaborate 
their own specific toxins. Some of them have a local as 
well as a general action, producing inflammation, necrosis, 
etc., when injected into living animals. 

Resistance of the Tissues to Bacteria. That the 
introduction of bacteria into the body is not always fol- 
lowed by the development of disease is due to a number 
of circumstances, one of the most important being the 
resistance offered by the tissues. Certain of the leuco- 
cytes have what is known as a phagocytic action — that 
is, the power to take into themselves and destroy by 
intracellular action the invading germs. The leuco- 
cytes appear to be attracted to the germs by a power 
residing in the bacteria, known as positive chemotaxis, their 
migration being accompanied by the nutritive changes con- 
stituting the process of inflammation, and in the case of 
pyogenic germs of suppuration. Inflammation seems to 
be a limiting and protecting process. The bacteria if very 
virulent may overcome the leucocytes, or repel them by 
the production of toxins, which are negatively chemotactic 
— that is, they repel the leucocytes and interfere with their 
phagocytic action, and we have in consequence a general 
invasion of the organism by the bacteria, often without 



114 MINOR SURGERY. 

any local inflammation. In addition to the phagocytic 
action of the leucocytes, the blood and fluids of the body 
have a certain germicidal power, said to be due to the 
presence of albuminous bodies — alexins. The presence in 
a wound of a foreign body favors the growth of bacteria, 
as does, to a certain extent, the presence of blood-clot or 
other material which can act as a culture medium for the 
germs. 

Immunity. This consists in the freedom from liability 
to a disease, and may be natural or acquired. In natural 
immunity the person or animal is immune from birth; 
while acquired immunity may be the result of a previous 
attack of the disease, or may be produced artificially. As 
examples of natural immunity we have that shown by the 
lower animals to syphilis and leprosy, and of man to cer- 
tain diseases of the lower animals. One attack of small- 
pox, scarlet fever, or typhoid fever confers an acquired 
immunity on the patient which is usually permanent; 
while an attack of pneumonia, influenza, or diphtheria is 
followed by a period of temporary immunity. Immunity 
may also be absolute or relative; the first being rare, the 
latter common, being overcome by unusual conditions. 
Artificial immunity is active or passive. Active immunity 
is obtained by the injection into animals of increasing 
doses of a pathogenic organism, or of its toxins, the dose 
being gradually increased until a high degree of immunity 
is obtained. This method is preventive of future attacks, 
but owing to its slowness is not useful against an existing 
disease. Passive immunity, which is less lasting than 
active immunity, is conferred by the iujection into an ani- 
mal of the serum of an animal that has been highly immu- 
nized by the previous method. The serum will destroy 
existing toxins and organisms, and confer temporary im- 
munity against further infection. 

Antitoxin. The mechanism of the production of im- 
munity is largely, if not altogether, dependent upon the 
formation by the reaction of the tissues to the toxins of 
an albuminous body known as antitoxin. To the presence 
of this substance in the serum of an actively immunized 



S UB OICAL BA CTEBIOL OGY. 115 

animal is due its curative power when injected into an 
animal suffering from the same disease. The antitoxin of 
diphtheria has been widely employed of late years with 
beneficial results, and the investigations now being carried 
on in tetanus, hydrophobia, anthrax, and other diseases, 
afford foundation for the hope that similar good results 
may be obtained with them. A distinction is made be- 
tween antitoxic serum and antimicrobic serum; the first 
being produced by the injection of toxins, and the latter 
by the injection of living bacteria. The antimicrobic 
serums tend to the destruction or paralysis of the micro- 
organisms, but not necessarily of the toxins. 

Varieties of Bacteria. 

The bacteria of importance surgically are those giving 
rise to ordinary suppuration, the gonococcus, the tubercle 
bacillus, the bacillus of malignant oedema, the bacillus of 
glanders, of anthrax, of tetanus, the bacillus of infectious 
emphysema, and the organisms causing actinomycosis and 
mycetoma. 

Bacteria of Suppuration. A large number of bac- 
teria are capable of giving rise to suppurative inflam- 
mation, but the most important are the staphylococci, 
especially the staphylococcus pyogenes aureus, and the 
streptococcus pyogenes or streptococcus erysipelatis, they 
being identical. Beside these, as rarer causes, we have 
the bacillus pyocyaneus, the bacillus coli communis, the 
typhoid bacillus, the gonococcus, the diplococcus pneumo- 
niae and the bacillus pneumoniae (Friedlander). 

The Staphylococcus Pyogenes Aureus. This bacillus, 
which causes 80 per cent, of suppurative inflammations, 
and is almost always the cause of osteomyelitis, grows in 
clusters (Fig. 106), can be cultivated on ordinary media, 
but best on agar, and forms small, round colonies, at first 
whitish, later of an orange-yellow color. It is found in 
health on the skin, in the pharynx, and in the external 
secretions. 

The staphylococcus pyogenes albus, or epidermis albus, as 



116 MINOR SURGERY. 

it is called, from being found in the epiderin, is less viru- 
lent than the preceding, and forms white colonies. It not 
infrequently is the cause of stitch abscesses. 

Fig. 106. Fig. 107. 

°$#&£ ^ \~ _~_ nO° O00 ° 

O 



Staphylococcus pyogenes aureus. Streptococcus pyogenes. 

(Abbott.) (Abbott.) 

Streptococcus Pyogenes. This is a small, round organ- 
ism which forms chains (Fig. 107). It is found occasion- 
ally on mucous surfaces in health, and causes dangerous 
phlegmonous inflammations. It also causes erysipelas, 
being identical with the streptococcus erysipelatis. 

Bacillus Coli Communis. This is a rod-shaped bacillus, 

and may be long and slender, or short and rounded. It 

strongly resembles the typhoid bacillus. It is provided 

with flagella. It is found in the intestines in health, and 

seems to acquire virulent properties from inflammation or 

strangulation of the bowel, giving rise to appendicitis and 

peritonitis by migration through the diseased wall of the 

bowel, or by escape through a rupture. It may also be 

the cause of cystitis, pyelitis, pyelo- 

FlG - 10S - nephritis, and occasionally of localized 

^ abscesses. 

M^\ ^Slfil Gonococcus. This is the germ of 

Vaf) ra^>^ gonorrhoea, is a kidney-shaped coccus, 

<£u- ^""* arranged in pairs, with the concave 



arranged in pairs, with the concave 
edges toward each other ; the diplo- 
|pB cocci usually inhabit the pus-cells, 

Gonococcus. (After bumm.) but are occasionally free (Fig. 108). 
Beside specific urethritis, it causes 
salpingitis, oophoritis, arthritis, endocarditis, conjunc- 
tivitis, proctitis, and other lesions. 

Tubercle Bacillus. This is the cause of tuberculosis, is a 
rod-shaped bacillus, sometimes slightly curved, 1.5 to 3.5 



SURGICAL BACTERIOLOGY. 117 

niicromilli metres in length and 0.2 to 0.5 micromillimetres 
thick. It is not motile, and occurs singly, in pairs, and 
in groups; spore production has not as yet been demon- 
strated (Fig. 109). Inoculation may be directly through 
a wound, or by inhalation, ingestion, or placental trans- 
mission, the last being rare. It may affect any organ of 
the body. It causes tuberculosis in many of the lower 
animals, cattle being especially liable to it. 

Fig. 109. 
,-■ •y ■-.;,.. : *&* . :. § 



<i i\-A\ .... ■ % MM 






Tubercle bacilli. (Abbott ) 

Bacillus Mallei. Glanders is caused by this bacillus, 
which resembles the tubercle bacillus, but is shorter and 
thicker (Fig. 110). Infection of the mucous membranes 
of the respiratory tract and through the skin is not uncom- 
mon in men who are exposed to infection from horses. 

Fig. 110. Fig. 111. 






Threads of bacillus anthracis con- 
Bacillus mallei. (Abbott.) taining spores. (Abbott.) 




118 MINOR SURGERY. 

Bacillus Anthracis. This, the cause of anthrax, is a 
very large, straight bacillus, usually from 5 to 20 micro- 
millimetres in length, sometimes, however, attaining a 
length of 50 micromillimetres. It forms long chains and 
produces spores, which are very resistant (Fig. 111). Infec- 
tion in man usually arises from handling infected skins and 
bides, and causes a local inflammation, with general septi- 
caemia. Infection may also take place through the lungs 
or through the gastro-intestinal tract. 

Bacillus of Tetanus. This is a rod-shaped organism 
which, owing to the formation of a spore at one end 
which distends it, is often of a drumstick shape (Fig. 
112). It is anaerobic, being found especially in garden- 
earth, in the excrement of animals, and around stables. 
Infection follows wounds, especially punctured wounds by 
nails or splinters, which are liable to be contaminated 
from the earth; infection is also quite common in puer- 
peral women and in the new-born. Suppuration in a 
wound favors its development. The bacterium apparently 
remains localized, producing its characteristic symptoms 
by the action of very powerful toxins, of which two, teta- 
nin and tetano-toxin, have been isolated. An antitoxin 
has been isolated from immunized animals, and some good 
results reported from its administration in individuals suf- 
fering from tetanus, but it has often proved disappointing. 



a 



Bacillus of malignant oedema, 
Tetanus bacillus. (Abbott.) spore stage. (Abbott.) 

Bacillus of Malignant (Edema. This resembles the an- 
thrax bacillus in appearance, being more slender, however, 
and, like it, has a tendency to form chains. It is motile, 



SURGICAL BACTERIOLOGY. 119 

being provided with flagella, is anaerobic, and forms spores 
(Fig. 113). It occurs in the soil, in dust, and in the con- 
tents of the intestines of lower animals. In the lower ani- 
mals it is the cause of the disease known as malignant 
oedema, which is associated with suppuration and necrosis 
of the subcutaneous tissues, emphysema, and gangrene. 
In man it has been found in certain cases of rapidly 
spreading traumatic gangrene and gangrenous emphy- 
sema, arising in connection with compound fractures and 
other deep punctured wounds. 

Bacillus Aerogenes Capsulatus. This organism is from 3 
to 6 micromillimetres in length, and may be found singly, 
clumped, or in chains. It is non-motile, anaerobic, and does 
not form spores. It finds entrance into the body through 
a wound or ulceration, external or internal, and its effects 
resemble somewhat those produced by the bacillus of ma- 
lignant oedema; viz., necrosis, gangrene, and the production 
of gas, which in this case is found in any or all of the tissues 
and organs and in the blood, in the form of minute bubbles, 
in the walls of which the bacilli may be found. In man it 
produces the condition which has been described as gaseous 
gangrene, infectious emphysema, gas phlegmon, and em- 
physematous necrosis. 

Fig. 114. 




Actinomyces. (Baumgarten.) 



Actinomyces, or Ray Fungus. This organism probably 
belongs to the higher order of bacteria, and occurs in yellow 



120 MINOR SURGERY. 

masses, which may be visible to the naked eye. They consist 
of masses of the organism, with diverging rays consisting 
of threads, with bulbous ends (Fig. 114). It occurs rarely 
in man, commonly in the lower animals, from whom it has 
been obtained in pure culture. When implanted in the 
tissues, to which it is conveyed through a wound or cari- 
ous tooth, sometimes apparently in seeds or in grains, it 
excites a chronic inflammation, with the presence of gran- 
ulation tissue, necrosis, and suppuration. In man it occurs 
most frequently in the mouth, tongue, and internal organs. 
In cattle it affects the jaws, causing " lumpy jaw." 

Mycetoma, or the Streptothrix Madurse. This is a branch- 
ing micro-organism, resembling the actinomyces, and, like 
it, occurring in granular masses, composed of branching 
threads. It excites in the foot especially the formation of 
nodular masses, which break down and form abscesses and 
fistulae, and causes caries and necrosis of the bones. 



THEORY OF ASEPSIS AND ANTISEPSIS IN WOUND 
TREATMENT. 

Before the introduction of Lister's method of treating 
wounds it was the rule in accidental and operative wounds 
to have profuse suppuration, fever, pain, and in many cases 
such wound complications as septicaemia, pyaemia, ery- 
sipelas, and hospital gangrene, and the mortality follow- 
ing operative and accidental wounds was very high. The 
mortality in compound fractures from sepsis was formerly 
very great, but by modern methods of wound treatment has 
been diminished to an insignificant percentage. The same 
diminished mortality has been found to follow amputations 
and other wounds, accidental or operative. 

Lister's method of wound treatment was largely based 
upon the idea that the infection of the wound occurred 
from contact with the air, which contained spores and 
germs, and his method of treatment was chiefly directed 
to their destruction. The air can be a medium of wound 
infection to a certain extent, for it has been demonstrated 



THEORY OF ASEPSIS AND ANTISEPSIS. 121 

that dry air contains dust in which spores and bacteria are 
present in much larger numbers than in moist air, and 
such air coming in contact with an open wound deposits 
there numbers of bacteria, which may set up inflammatory 
changes. Koch later demonstrated the fact that atmos- 
pheric microbes were chiefly of an innocuous character, 
and that wound infection was generally caused by bacteria 
or spores being brought in direct contact with the wound 
by the clothing and skin of the patient, the instruments 
and the hands of the surgeon and assistants, and unclean 
surgical dressings. 

Cheyne has shown that the relative number of bacteria 
entering the tissues is an important factor in producing 
suppuration and septic infection, for we know that bacte- 
ria may exist in an aseptic wound and yet the wound heal 
and remain aseptic, the antiseptic qualities of the blood- 
serum and the cell-activity in healthy tissues being suffi- 
cient to destroy or remove a certain number of micro- 
organisms, and suppuration or septic infection occurring 
only when the tissues are ovewhelmed by the number of 
organisms, or when their power of resistance is diminished 
by injury or disease. This explains the satisfactory be- 
havior of wounds which pursue an aseptic course where 
very imperfect details of aseptic or antiseptic treatment 
have been employed. It may, therefore, be assumed that 
infection does not necessarily depend upon the presence of 
a few microbes, but rather upon the quantity and quality 
of the germs which are present in the wound. 

Pyogenic micro-organisms under different conditions can 
produce a series of different diseases, for it is now gener- 
ally accepted that Fehleisen's streptococcus erysipelatis is 
identical with streptococcus pyogenes, which is recognized 
as the cause of very different inflammatory affections. 
The theory has been advanced by Reger that all the so- 
called pus-diseases are simply local expressions of a gen- 
eral infection caused by many different micro-organisms. 

Sepsis. Sepsis is due to the entrance and multiplica- 
tion of micro-organisms or the absorption of their products 
in the body, and is characterized by local inflammation of 



122 MINOR SURGERY. 

the wound, and marked constitutional symptoms, such as 
fever, disorders of the nervous system, and inflammation 
of the viscera. Microbic infection represents a patholog- 
ical process which causes serious wound complicatious, and 
differs materially from that process which attends the re- 
pair of wounds that run an aseptic course. Aseptic chem- 
ical irritation of the tissues may result in the production 
of a puruloid fluid, which is not pus, but merely a fibrinous 
exudatiou containing numerous cells, and does not produce 
infection if injected into animals. Acute suppuration in a 
wound is considered clinically to be always due to the 
presence of bacteria, for their exclusion will prevent its 
occurrence. 

Asepsis. Asepsis aims at thorough sterilization of the 
parts and of all objects brought in contact with the wound, 
and the exclusion of micro-organisms by occlusive steril- 
ized dressings. 

Antisepsis, on the other hand, has in view the destruc- 
tion of micro-organisms by keeping germicidal agents con- 
stantly in contact with the wound. The object of anti- 
sepsis is, therefore, to produce asepsis. 

No surgeon should undertake the performance of an 
operation or the treatment of an open wound without 
having clearly impressed upon his mind the important 
part that pyogenic and specific micro-organisms may play 
in the subsequent course of the wound. 



Methods of Disinfection or Sterilization. 

Since the majority of wound complications are due to 
the presence in the wound of micro-organisms, it is the 
duty of the surgeon to prevent their contact with it, or to 
employ means for their destruction. We must, however, 
employ means of disinfection or destruction of these micro- 
organisms which will not have any injurious effect upon 
the tissues with which they come in contact. Mechanical 
disinfection or sterilization is not applicable to wounds, but 
is employed to remove any micro-organisms which may be 
present upon the objects which are to come in contact with 



THEORY OF ASEPSIS AND ANTISEPSIS. 123 

the wound — namely, the hands of the surgeon and assist- 
ants, instruments, and the skin surrounding the wound. 
Mechanical disinfection is accomplished by the use of fric- 
tion with a brush, soap, and water. Germicidal solutions 
may be used for disinfection of wounds, but are most use- 
ful in the disinfection of the hands of the operator, the 
skin of the patient, the instruments, and the dressings. 
If these have been carefully employed before the wound 
is made, their subsequent use in the wound is usually 
unnecessary. 

Some forms of bacilli contain spores which resist the 
action of germicidal substances, while the bacilli them- 
selves are readily destroyed by these agents : the surgeon 
should, therefore, employ that means of disinfection which 
is generally applicable to the destruction of both bacilli 
and their spores. The bacilli of anthrax, tuberculosis, and 
tetanus contain spores; hence to destroy these organisms 
is a matter of more difficulty than to render harmless 
such micro-organisms as staphylococcus pyogenes aureus, 
albus, and citreus, streptococcus pyogenes and streptococcus 
erysipelatis, and the bacilli of diphtheria and glanders, 
which contain no spores. 

Heat when used as a germicide cannot be applied to the 
wound itself, except in cases where a limited amount of 
the surface of the wound may be touched with the hot 
iron. Heat can, therefore, be used only for the disinfec- 
tion of substances coming in contact with the wound, and 
for this purpose it is employed in the form of steam, dry 
heat, or boiling water. 

Sterilization of the wound or the substances coming in 
contact with it may be accomplished by using either the 
aseptic method or the antiseptic method, and at the present 
time these two methods are to a certain extent combined — 
that is, it is impossible to be strictly aseptic without em- 
ploying means of disinfection by the use of antiseptics. 
The aseptic method, which employs germicidal substances 
only for the purpose of sterilization of objects coming in 
contact with the wound, when their disinfection by heat is 
impossible, is the method which has been generally adopted. 



124 MINOR SURGERY. 

Antiseptic Method. In the antiseptic method the ster- 
ilization of the field of operation, the hands of the surgeon 
and assistants, the instruments, ligatures, sponges, and 
sutures, is accomplished by the use of germicidal solutions, 
and, in addition, the wound is irrigated frequently during 
the operation with germicidal solutions, and is afterward 
covered with dressings impregnated with germicidal sub- 
stances. The antiseptic method was that first employed, 
and, recognizing its value in surgical procedures, many 
surgeons still continue to employ this method, but it has 
certain disadvantages. Recent investigations have shown 
that many of the germicidal substances have not the power 
which was formerly attributed to them; many chemical 
germicides cause the formation of a dense layer of coagu- 
lated albumin around albuminous substances, and also fail 
to destroy micro-organisms associated with fatty or oily 
substances. Chemical germicides may also form combina- 
tions in the tissues with substances with which they come 
in contact, seriously impairing their germicidal action. 
Antiseptic substances which are active as germicides often 
cause irritation of the surface of the wound, interfering 
with its repair. 

It has been shown that irrigation of a fresh wound with 
a 1 : 10,000 solution of bichloride of mercury is followed 
by distinct evidence of superficial necrosis of the tissues. 
Antiseptic irrigation of wounds is apt to cause very free 
oozing of serum, which necessitates the use of drainage, 
and makes the frequent dressing of the wound necessary. 
Many antiseptic substances produce marked toxic effects 
upon the patient, and also cause very severe irritation of 
the skin with which they come in contact. 

Aseptic Method. In employing the aseptic method in 
the treatment of wounds the field of operation, the hands 
of the surgeon and assistants, the instruments, ligatures, 
sponges, and sutures, are sterilized by the use of germi- 
cidal solutions and heat, and after this has been accom- 
plished, relying upon the completeness of the sterilization, 
no germicidal substances are brought in contact with the 
wound, sterilized water or sterilized salt solution being 



SEAT. 125 

used if it is necessary to flush the wound, and the dress- 
ings employed are those only which have been sterilized 
by moist or dry heat. The advantages of the aseptic 
method are as follows : the method is applicable to all 
parts of the body; wounds treated by this method heal 
more promptly and do not require such frequent dressing; 
there is no risk of toxic effects, and there is no irritation 
of the skin by the dressings. Dry sterilized dressings are 
efficient to produce absorption, and at the same time the 
dryness may be a factor in the destruction of germs, for 
exposing bacteria to dryness deprives them of one of the 
conditions necessary to their existence. The aseptic method 
is, therefore, to be preferred to the antiseptic method in 
the treatment of wounds wherever it is possible. 

Agents Employed to Secure Asepsis. 

A great variety of agents possessing more or less germi- 
cidal properties have been at different times employed in 
the practice of aseptic or antiseptic surgery; those most 
employed at the present time are heat, bichloride of mer- 
cury, carbolic acid, iodoform, formalin, beta-naphthol, for- 
maldehyde, chloride of zinc, acetate of aluminum, peroxide 
of hydrogen, kreolin, permanganate of potassium, sulpho- 
carbolate of zinc, salicylic and boric acid, acetanilid, aris- 
tol, and certain silver salts. 

Heat. The most reliable and universally available 
agent for the destruction of micro-organisms is heat, either 
dry or moist; many forms of bacteria are rendered inert 
at a temperature of 140° F., and none can withstand the 
application of moist heat at a temperature of 212° F. con- 
tinued for a short time. Spores which will resist the 
action of powerful germicides for a considerable time are 
destroyed by boiling for a few minutes. As moist heat is 
the most efficient sterilizer, it should be preferred, and can 
always be made use of for this purpose by boiling the 
instruments and dressings for a few minutes, and if for 
any reason it is thought advisable to employ dry heat as a 
sterilizer, this may be made use of by baking the instru- 



126 



MINOR SURGERY. 




Steam sterilizer. 



ments or dressings in a hot oven. The best results may 
be obtained by the use of one of the various dry or moist 
sterilizers (Fig. 115). An improvised sterilizer may be 
made by having a perforated metal stand placed inside a 

large kettle so that only the 
FlG - 115 - steam comes in contact with 

the instruments and dress- 
ings. 

Bichloride of Mercury. 
This is employed as an anti- 
septic in watery solution, vary- 
ing in strength from 1 : 500 
to 1 : 10,000. 

The solution of 1 : 500 to 
1 : 1000 is used only for the 
irrigation and disinfection of 
the hands and skin .; for the 
irrigation of wounds, a solu- 
tion of 1 : 2000 or 1 : 4000 is 
generally employed. Where continuous irrigation is kept 
up, or where it is employed in large cavities, a still weaker 
solution, 1 : 5000 to 1 : 10,000, should be employed. 

In using bichloride solutions the surgeon should watch 
the patient carefully for symptoms of poisoning due to the 
absorption of the bichloride of mercury; the symptoms 
denoting this are vomiting, fetid breath, salivation, inflam- 
mation of the gums, diarrhoea, blood-stained stools, and 
bleeding from the mouth and nose. 

In preparing the solutions of bichloride of mercury for 
use it will be found convenient to have a concentrated 
solution of the salt in alcohol, one part of the bichloride 
of mercury to ten parts of alcohol; this can be kept in a 
well-stoppered bottle, and to this should be added one tea- 
spoonful of common salt, which prevents the disintegra- 
tion of the mercuric compound. One teaspoonful of this 
solution added to one quart of water makes a 1 : 2500 
solution. 

A 10 per cent, bichloride solution may be made as fol- 
lows : 



CARBOLIC ACID. 127 

Bichloride of mercury 2 parts. 

Sodium chloride 1 part. 

Dilute acetic acid 1 " 

Water 16 parts. 

By adding water in an appropriate quantity, a 1 : 1000 or 1 : 2000 solution can be 
made. 

Or the solution may be prepared with tartaric acid in the 
proportion of five parts of the acid to one part of the 
bichloride of mercury, the following formula being em- 
ployed : 

Hydrarg. chlor. corrosiv grs, xv. 

Ac. tartaric. grs. lxxv. 

Aquae dest Oij. 

Pellets containing a definite amount of bichloride of 
mercury compounded with a few grains of common salt of 
muriate of ammonia, which, when dissolved in a definite 
quantity of water, make a solution of 1 : 1000 or 1 : 2000, 
will also be found very convenient for the preparation of 
solutions. The pellets should also contain a little coloring 
matter, which gives a faint color to the solution and serves 
to distinguish it from other solutions. 

Carbolic Acid. This drug is employed in solutions of 
1 : 20 or 1 : 40. The stronger solution, 1 : 20, is usually 
employed to sterilize the instruments, the latter being 
allowed to remain in this solution for thirty minutes be- 
fore being used. As a carbolic solution of this strength 
benumbs and cracks the skin of the hands of the operator, 
it should be diluted just before the instruments are re- 
quired, by adding an equal quantity of water, making it 
a 1 : 40 solution. 

The 1 : 40 or 1 : 60 solution is used for the irrigation of 
wounds and the washing of sponges. A ready method of 
making a 5 per cent, carbolic solution is to add one table- 
spoonful of carbolic acid to one pint of hot water. 

In using carbolic acid solutions continuously the sur- 
geon should be on the watch for the symptoms of poison- 
ing, which will show itself by dark-colored urine, head- 
ache, dizziness, vomiting, and in severe cases bloody diar- 
rhoea, haamoglobinuria, and death from collapse. Carbolic 
acid solutions should be used with great caution in young 



128 MINOR SURGERY. 

children, as they seem to be more susceptible than adults 
to the constitutional effects of this drug. 

The use of weak solutions of carbolic acid seems to 
involve more risk of toxic action than does the employ- 
ment of the pure drug, the superficial layer of tissue being 
coagulated by the latter, so that the absorption of the drug 
is prevented. Gangrene of the skin and subjacent tissues 
has frequently been observed to follow long-continued use 
of quite dilute solutions of carbolic acid or of ointments 
containing small quantities of the drug. Cases of gan- 
grene of the fingers and toes from this cause are not infre- 
quently seen. 

Iodoform. Iodoform has been shown by experimental 
research to possess little direct germicidal action, but in 
spite of this fact, clinical experience has proved that it 
possesses powerful antiseptic properties, due, as shown by 
Behring and De Ruyter, not to the destruction of germs, 
but to its undergoing a decomposition in their presence, and 
thus rendering inert the ptomaines which have resulted 
from the germ-growth. It may be rendered absolutely 
sterile by exposing it to heat, and, as it is easily decom- 
posed, fractional sterilization may be employed, or by 
washing it in a 1 : 1000 bichloride solution; it should then 
be dried and kept for use in closely stoppered bottles. 
Iodoform is employed as an application to wounds, and is 
frequently employed in aseptic wounds which are liable 
from their position to become infected, such as those 
about the mouth, rectum, and vagina, and is especially 
useful as a dressing in infected wounds and in tubercular 
or syphilitic ulcers. In operations upon the mouth, anus, 
rectum, uterus, and abdominal cavity iodoform gauze 
packing is largely employed, and serves to keep the dis- 
charges from becoming foul, thus often preventing septic 
intoxication. It is often used in the form of powder. 
Iodoform collodion, made by adding iodoform, gr. xlviii, 
to collodion, fgj, is a useful dressing in superficial wounds. 
It may also be employed in the form of an ethereal solu- 
tion, iodoform, gr. xv; ether, f§j, as an application to 
wounds or ulcers. An emulsion of iodoform in glycerin, 



FORMALIN. 129 

iodoform, 3j; sterilized glycerin, 5x, or an emulsion of 
iodoform made by adding sterilized iodoform, 5j ; to boiled 
olive oil, 5x, is much employed as an injection in the treat- 
ment of tubercular abscesses and joints. 

Numerous cases have been reported in which toxic symp- 
toms have followed the use of iodoform, such as urticarial 
eruptions, headache, depression, delirium, mania, debility, 
and sleeplessness. Elderly persons and infants are very 
susceptible to the toxic action of iodoform. 

Formaldehyde. This is a pungent, penetrating gas pos- 
sessing valuable antiseptic properties, which is principally 
used for the disinfection of clothing, instruments, bedding, 
and rooms. The gas is generated in a lamp or generator 
by passing the vapor of methyl alcohol over a coil of glow- 
ing platinum wire or gauze, or over platinized asbestos. 

Formalin. This is a 40 per cent, solution of formal- 
dehyde gas in water, and has valuable antiseptic proper- 
ties. A solution of this strength is a powerful irritant, and 
cannot be used in the treatment of wounds. It may be 
used in a 2 per cent, solution to disinfect wounds or instru- 
ments, or in a one-quarter of 1 per cent, solution for irri- 
gation. 

Formalin-gelatin or Glutol. This is a compound 
formed by evaporating an aqueous solution of gelatin 
over vapor of formalin. Its activity as an antiseptic de- 
pends upon the vapor of formalin given off when applied 
to the wound. It is a non-irritating and non -poisonous 
powder. 

Beta-naphtol. Beta-naphtol, in a 1 : 2500 solution, is 
employed for much the same purposes as the bichloride of 
mercury solution; it is not, however, so powerful a germi- 
cide. It is employed in irrigating large cavities because 
it is not a poisonous agent, but is especially useful as a 
bath for instruments, as it does not corrode them, as does 
the sublimate solution. It also possesses the advantage 
over a carbolic acid solution of not irritating the skin of 
the surgeon's hands. 

Silver Salts. Silver lactate (actol) and silver citrate 
(itrol) are two new antiseptics which have been recom- 

9 



130 MINOR SURGERY. 

mended by Crede, who considers their germicidal proper- 
ties superior to bichloride of mercury. These salts may 
be used in a 1 : 4000 or 1 : 8000 solution, which should be 
made in water free from chlorides, which precipitate the 
silver; distilled water should be employed. Crede speaks 
highly of an ointment made of metallic silver which may 
be employed as an inunction in septic diseases. 

Acetanilid. This preparation possesses antiseptic prop- 
erties and is frequently used as a substitute for iodoform. 
It may be used in the form of powder as an application to 
suppurating or ulcerating tissues, but in tubercular condi- 
tions is not as satisfactory as iodoform. 

Chloride of Zinc. Chloride of zinc, in a solution of 
30 to 40 grains to water f5j, is a very powerful antiseptic. 
When employed upon raw surfaces it produces marked 
blanching of the tissues; it is especially useful in wounds 
which are infected or which have been exposed to infec- 
tion. I have found it by all means the best application 
for the poisoned wounds which are received in dissecting 
dead bodies and in operating. In such cases the whole 
cavity or surface of the wound should be washed with a 
30-grain solution of the chloride of zinc, and then the 
wound should be dressed with a moist bichloride dressing. 

Sulpho-carbolate of Zinc. This drug has been found 
to possess more decided antiseptic properties than the chlo- 
ride of zinc, and is much less irritating. It may be used 
in the same strength and for the same purposes as the 
former drug. 

Acetate of Aluminum. This drug is used in solution 
and is prepared as follows : Aluminis, 5vj (24 grammes); 
plumbi acetatis, 5jxss (38 grammes); aquae, Oij (1000 
grammes). Mix and filter after standing twenty-four 
hours. It has decided germicidal qualities, is employed 
for irrigation and moist dressing where carbolic or bichlo- 
ride solutions cannot be used, and is by all means the 
safest and best antiseptic substance for wet dressings. 

Peroxide of Hydrogen. Peroxide of hydrogen is em- 
ployed in what is known as the 15-volume solution. It 
may be used in this strength or may be diluted. It seems 



BORIC ACID. 131 

to have a direct action upon pus-generation by destroying 
the micro-organisms of pus, and is frequently employed in 
the sterilization of sinuses or suppurating cavities, such as 
remain after the opening of abscesses or result from dis- 
eases of or operations upon the bones. It is injected into 
the sinuses and cavities by means of a glass syringe, or 
may be applied to open wounds in the form of a spray. 
Its action is shown by the escape of bubbles of gas, which 
cleanse suppurating surfaces or sinuses mechanically, and 
it should be used as long as these continue to escape. 

Pyrozone. Pyrozone possesses the same qualities as the 
peroxide of hydrogen, and apparently to a somewhat higher 
degree, and is used for the same purposes. 

Kreolin. This substance is obtained from English coal 
by dry distillation, and has been found to possess powerful 
germicidal properties; it is non-irritating and practically 
non-toxic. It is insoluble in water, but forms an emul- 
sion with it which possesses marked antiseptic properties. 

It may be employed for the same purposes as carbolic 
acid, and has the advantage over the latter drug that it is 
not irritating to the skin, and is almost devoid of toxic 
properties. 

It is used in an emulsion, in strength from 2 to 5 per 
cent., and is employed in the irrigation of large wounds 
or cavities of the body, and has been most favorably 
recommended in gynecological practice. 

Boric Acid. This drug has not very marked antiseptic 
qualities, and is usually unirritating even in saturated 
solutions. It is frequently employed in a 5 per cent, 
solution to cleanse and disinfect mucous surfaces and large 
cavities. It is often employed to wash out the bladder 
before the operation for the removal of calculi or growths 
from that organ. 

In the dressing of superficial wounds, or in wounds in 
which the bichloride or carbolic acid dressings produce 
irritation, an ointment of boric acid, 1 part, to petrolatum 
5 parts, will be found very satisfactory. 

Salicylic Acid. Salicylic acid does not have very 
marked antiseptic qualities, but possesses much less toxic 



132 MINOR SURGERY. 

action than carbolic acid, and is used for somewhat the 
same purposes. Its antiseptic power is said to be increased 
by the addition of boric acid, and a boro-salicylic lotion 
(Thiersch's solution) is prepared by adding salicylic acid, 
1 part; boric acid, 6 parts; to hot water, 500 parts, making 
a bland solution, which, when reduced from 25 to 50 per 
cent, in strength, can be used for irrigation of the bladder 
or the peritoneal cavity. 

Permanganate of Potassium. This drug, owing to its 
rapid absorption of oxygen, acts as an antiseptic, and is 
often employed for the disinfection of foul wounds and 
ulcers. It is also employed in solution for washing the 
operator's hands and for the washing of sponges. It is 
practically non-irritating, and may be used in quite con- 
centrated solutions, but is usually employed in the follow- 
ing solution: Permanganate of potash, 3j; water, f§j. 
One fluid drachm of this solution to a pint of water makes 
a 1 : 1000 solution. 

Aristol. Aristol, which is a compound of iodine and 
thymol, possesses germicidal properties, and has been in- 
troduced as a substitute for iodoform. It has the advan- 
tage over iodoform of not being poisonous, and is also 
without disagreeable odor. It may be employed for the 
same purposes as iodoform, and it seems to be particularly 
useful as a dressing to chronic and specific ulcers. 



PREPARATION OF MATERIALS USED IN ASEPTIC 
OPERATIONS. 

Sponges. Marine sponges are the best materials for 
the purpose of sponging, but their satisfactory sterilization 
is often a matter of difficulty. It is better to use a cheap 
grade of sponges and use them only once. The steriliza- 
tion of sponges by boiling destroys to a certain extent 
their elasticity and their absorbent power. Schimmel- 
busch recommends the following method. The dried 
sponges are freed from dirt or sand by beating, and are 
then soaked for several days in cold water slightly acidu- 



SPONGES AND GAUZE PADS. 133 

lated with hydrochloric acid, being kneaded from time to 
time. They are next thoroughly washed in cold and in 
warm water, wrapped up in a linen sheet, and placed in a 
boiling 1 per cent, soda solution; the solution should not 
be allowed to boil after the sponges are placed in it. They 
are allowed to remain in this hot solution for thirty min- 
utes, are then washed in boiled water to remove the soda, 
and are placed in a 0.5 per cent, bichloride solution for use. 

Another method of preparing the sponges consists in 
beating them to remove any sandy matter which they may 
contain, and placing them for twenty-four hours in a solu- 
tion of hydrochloric acid, 4 ounces; water, 4 pints; upon 
removing them from this solution, they are washed until 
free from acid; they are then placed for half an hour in a 
solution of permanganate of potassium, 180 grains to 6 
pints of water; next they are washed and placed in a solu- 
tion of hyposulphite of sodium, 10 ounces; hydrochloric 
acid, 5 ounces; water, 48 ounces, and allowed to remain 
in this solution for four hours; then they are removed and 
placed in running water for six hours, and afterwards in a 
5 per cent, carbolic acid solution or a 1 : 1000 bichloride 
solution. Carbolic solution is the better one, as it is not 
so liable to decomposition. 

Gauze Pledgets or Pads. On account of the difficulty 
of the satisfactory sterilization of sponges, as well as of 
their expense, folded gauze pledgets have largely super- 
seded them. 

Gauze Pledgets. Gauze pledgets are prepared by cutting 
a piece of gauze, composed of from twelve to sixteen layers, 
in pieces six inches square; the four angles of these pieces 
are then tied together or secured by a few stitches. 

Gauze Pads. Gauze pads are made from a piece of gauze 
composed of from sixteen to twenty layers cut the desired 
size, the different layers in each pad being quilted together 
by a few stitches, and the edges loosely whipped with a 
thread to prevent them from fraying. Gauze pads are 
used as a substitute for the flat sponges formerly employed 
in abdominal surgery, and for the drying of wounds. The 
pads or pledgets may be sterilized by boiling or by expo- 



134 MINOR SURGERY. 

sure to steam or dry heat in a sterilizer, or may be steril- 
ized and preserved at the same time in a 1 : 2000 bichloride 
solution. When so preserved, before being employed the 
moisture should be squeezed from them, or they should be 
washed in water which has been boiled before being brought 
in contact with the wound. 

Silk Sutures and Ligatures. Silk for sutures or liga- 
tures, either the plaited silk or the Chinese twisted silk, 
should be sterilized by boiling from ten to thirty minutes in 
a 5 per cent, solution of carbolic acid, or in water, the time 
of boiling depending upon the thickness of the threads; 
frequent boiling renders the silk weak. It should then be 
placed in stoppered bottles and covered with a 5 per cent, 
solution of carbolic acid or with absolute alcohol, or in 
1 : 1000 bichloride and alcohol solution. 

Silkworm-gut. Silkworm-gut is an excellent material 
for sutures, and may be sterilized by boiling it for fifteen 
minutes, or by placing it for one half hour in a 5 per cent, 
carbolic solution; after being sterilized it should be kept 
in 95 per cent, alcohol. There has recently been intro- 
duced an iron-dyed black silkworm-gut, which makes the 
sutures more prominent, and thus facilitates their removal. 

Catgut Ligatures and Sutures. Catgut is the ideal 
material for ligatures and sutures, but has the disadvan- 
tages of difficulty and uncertainty in its sterilization. 
Raw catgut is often infected with micro-organisms, and, 
therefore, thorough sterilization alone can render it a safe 
material for ligatures and sutures. 

Von Bergmann's Catgut. This method of preparing cat- 
gut, which we have found one of the most satisfactory, 
consists in winding the catgut loosely upon glass rods or 
spools; these spools are placed in ether for twenty-four 
hours; the ether is then poured off, and the catgut is 
placed in the following solution : bichloride of mercury, 
10 parts; absolute alcohol, 800 parts; distilled water, 200 
parts. Remove from this solution in twenty-four hours, 
and place it in a similar solution for forty-eight hours; 
then place it in absolute alcohol. If you desire the gut 
to be soft, add 20 per cent, of glycerin to the absolute 



CA TG UT LIGA TUBES. 135 

alcohol. To make the sterilization absolutely certain it 
has been found advantageous to soak the catgut for thirty 
minutes in a 1 : 1000 aqueous bichloride solution before 
placing it in the alcoholic solution of bichloride. 

Dry Sterilized Catgut. Boeckman's process for steriliz- 
ing catgut consists in cutting the gut in pieces twenty to 
forty inches in length ; each piece is wrapped in paraffin- 
paper, and sealed in a paper envelope. The envelopes are 
then placed in a sterilizer for three hours at a temperature 
of 284° F., and then for four hours longer at a tempera- 
ture of 290° F. When required for use the envelope is 
opened, the paraffin-paper removed, and the gut is im- 
mersed for a few minutes only in sterilized water. 

Boiled Catgut. Catgut may also be sterilized by boiling. 
The most satisfactory method is that devised by Fowler, 
which consists in placing a number of strands of catgut in 
an ordinary test-tube which is filled with 95 per cent, alco- 
hol to within half an inch of the top; a wad of cotton is 
next pushed into the mouth of the tube, and a cork is 
introduced. The tubes thus prepared are placed inverted 
in a fruit-jar filled with 95 per cent, alcohol; the jar is 
then closed and placed in a water-bath and kept at a boil- 
ing temperature for an hour. 

Formalin Catgut. This is prepared by winding catgut 
loosely on glass spools and keeping them for forty-eight 
hours in a vessel containing equal parts of alcohol and 
ether. They should next be washed for a few minutes in 
alcohol and placed in a jar containing equal parts of alco- 
hol and formalin, and allowed to remain for several days. 
The excess of formalin should then be washed away with 
alcohol, and the catgut kept for use in 95 per cent, alcohol. 

Cumol Catgut. This is prepared by first placing catgut 
in a hot-air oven at a temperature of 70° C. for two hours. 
It is then placed in cumol at a temperature of 165° C. for 
one hour. It should then be placed in petroleum benzine 
for permanent preservation. 

Chromicized Catgut. Owing to the fact that it undergoes 
very slow solution in the tissues, chromicized catgut is 
often of service for sutures or for the ligation of the larger 



136 



MINOR SURGERY. 



vessels in their continuity. It may be prepared by placing 
catgut which has been sterilized by being treated with the 
alcoholic bichloride solution in one quart of a 5 per cent, 
carbolic acid solution which contains 30 grains of bichro- 
mate of potassium, allowing it to remain for forty-eight 
hours; this immersion should be longer when the larger 
sizes of catgut are used, but for the sizes of catgut which 
are ordinarily employed this length of immersion will pre- 
pare the gut to resist the action of the living tissues for a 
week or more. Catgut thus prepared may be dried and 
placed in closely stoppered jars, or may be kept in abso- 
lute alcohol. Before being used it should be soaked for 
thirty minutes in a 5 per cent, carbolic solution or a 
1 : 2000 bichloride solution. 



Fig. 116. 



Fig. 117. 





Rubber drainage-tube. 



Glass drainage-tube. 



A very simple method of carrying catgut and keeping 
it sterile consists in using a strong glass tube, about an 



DRAINAGE TUBES. 137 

inch in diameter and six inches in length, into each end 
of which is fastened a rubber cork. A number of glass 
spools wound with sterilized catgut of various sizes are 
fitted into this glass tube; one cork is introduced; the 
tube is then filled with alcohol or a 1 : 2000 bichloride 
solution in alcohol, and the other cork is introduced, or a 
test-tube and a rubber stopper may be used. 

Drainage-tubes. The drainage-tubes usually employed 
are prepared from rubber-tubing of different sizes perfor- 
ated at short intervals; the black rubber tubes are softer 
and more pliable than the red or white rubber tubes, and 
should be preferred (Fig. 116). Drainage-tubes are also 
made of glass, straight or curved (Fig. 117), which are 
almost exclusively used in abdominal surgery, and also of 
decalcified bone. Drainage-tubes should be kept in a 5 
per cent, solution of carbolic acid, or, if kept dry, they 
should be well washed and sterilized by boiling water 
for a few minutes before being used. 

Catgut and Horsehair Drainage. Catgut as ordi- 
narily prepared for ligatures may be used to secure drain- 
age in small and superficial wounds; a number of strands 
of catgut are placed in the bottom of the wound, and the 
ends are allowed to project from one or both extremities 
of the wound. 

Horsehair may be employed for the same purpose, a 
number of strands of the hair being placed in the wound 
in the same manner. Before being used it should be well 
washed with soap and water and then soaked in a 5 per 
cent, carbolic solution or 1 : 1000 bichloride solution for 
thirty minutes. 

Protective. Protective is employed to prevent the 
wound from being irritated by the antiseptic substances 
with which the gauze is impregnated or by its irregular 
surface. The great objection to the use of protective is 
that it sometimes interferes with drainage, and permits of 
the accumulation of serum beneath it, which may become 
infected and cause infection of the wound. 

Various materials are employed as protectives, the prin- 
cipal requirement being that they are some tissue which 



138 MINOR SURGERY. 

can be readily rendered aseptic and does not absorb any 
irritating materials from the dressings. 

The protective first employed by Mr. Lister, which is 
still generally used, is prepared by coating oiled silk with 
copal varnish, and when this is dry a mixture of 1 part of 
dextrine, 2 parts of powdered starch, and 16 parts of a 
1 : 20 carbolic acid solution is brushed over its surface. 
Rubber- tissue may be employed very satisfactorily as a 
substitute for this protective. 

Before applying the protective to the wound, it is 
soaked in a solution of bichloride of mercury or carbolic 
acid. 

Silver Foil. The inhibitive action of metallic silver on 
the growth of micro-organisms is utilized in the employ- 
ment of silver foil to cover the surface of wounds. The 
foil is sterilized by dry heat and placed directly on the 
surface of the wound after it has been closed by sutures. 
It is claimed that the foil prevents the infection of the 
wound from the exterior, and also destroys micro-organ- 
isms which may come in contact with it. 

Mackintosh. This consists of cotton- cloth, with a thin 
layer of India-rubber spread on one side. It is employed 
in antiseptic dressings as the layer placed outside of the 
gauze, and should be applied with the rubber surface to- 
ward the wound, to prevent the entrance of air and to 
allow the serum from the wound to permeate the gauze 
and not soak directly through the dressings. 

The mackintosh cloth is not at the present time as much 
employed as formerly, unless the moist method of dressing 
is adopted. 

Rubber-dam. This is a thin, pure rubber-tissue, and 
as it has no cloth surface like mackintosh, it is cleaned 
and sterilized with greater facility. It is used in applying 
the moist method of dressing to cover the gauze dressings, 
and is attached to the drainage-tube in abdominal wounds 
to shut off the opening of the tube from the abdominal 
wound. Before being used it should be washed with soap 
and water, rinsed, and then placed in a bichloride or car- 
bolic solution for a time sufficient to sterilize it. 



G A UZE DRESSINGS. 139 

Rubber-tissue. This consists of a very thin sheet of 
India-rubber with glazed surfaces, which can be obtained 
from the rubber-manufacturers; it is employed for the 
same purposes as the mackintosh, is much less expensive, 
and, as previously stated, may be used when properly 
sterilized instead of protective for covering the wound. 

Gauze Dressings. 

The most convenient and cheapest material for wound 
dressing is a material known to the trade as cheese-cloth 
or tobacco-cloth, and for surgical use should contain no 
sizing. From the fact that it has a very open mesh it 
absorbs well either the materials with which it is prepared 
or the discharges from the wound, and is soft and pliable, 
so that it is a comfortable form of dressing to the patient. 

Bichloride or Corrosive Sublimate Gauze. Bichloride 
or corrosive sublimate gauze is prepared by placing cheese- 
cloth in a washing-kettle and covering it with water to 
which is added two pounds of washing soda or a pint of 
lye; the latter is added to remove any oily matter which 
the cheese-cloth contains, thus making it more absorbent. 
The gauze is boiled in this solution for an hour, and is 
then removed and washed in boiled water and passed 
through a sterilized clothes-wringer; it is then immersed 
in a 1 : 1000 bichloride solution for twenty-four hours; the 
excess of fluid is then squeezed out of it, and it may be 
packed in air-tight jars and preserved as a moist gauze, or 
may be dried in a warm oven and packed in sterilized jars 
and kept as a dry gauze. 

In using the sublimate gauze on delicate skins there will 
sometimes result a dermatitis, which is known as mercu- 
rial eczema; this is particularly apt to occur if the gauze 
is moistened or covered with rubber-tissue or mackintosh. 
If this condition develops, the parts covered by the gauze 
should be rubbed over with boric acid ointment or vase- 
line before it is reapplied, or a sterilized gauze dressing 
should be substituted. 

Iodoform Gauze. This may be prepared by soaking 
sterilized gauze in a mixture containing iodoform, 5 parts; 



140 MINOR SURGERY. 

glycerin, 20 parts, and alcohol, 70 parts. This furnishes 
the 5 per cent, iodoform gauze; if 10 per cent, gauze is 
desired, the quantity of iodoform should be doubled. 
When the gauze is thoroughly saturated it should be of a 
uniform yellow color. It should then be thoroughly 
wrung out with sterilized hands to remove the alcohol, 
and packed in aseptic jars, with tight-fitting covers. 

Iodoform gauze may also be prepared by saturating 
sterilized gauze with a mixture of ether and iodoform, 
and then allowing the ether to evaporate, the iodoform 
being distributed evenly through the gauze. 

Carbolized Gauze. In preparing carbolized gauze, 
cheese-cloth which has been previously boiled and dried 
is soaked for a few hours in the following solution : resin, 
1 pint; alcohol, 5 pints; castor oil, 24 ounces; carbolic 
acid, 12 ounces. The gauze is removed from this solution 
and passed through a sterilized clothes-wringer, and is 
then cut into pieces from four to six yards in length, 
which are folded and packed in air-tight jars for use. 

Improvised Aseptic or Antiseptic Dressings. Asep- 
tic dressings in cases of emergency may be improvised, 
where the ordinary gauze dressings cannot be obtained, by 
tearing a piece of muslin or mosquito netting into pieces 
half a yard square and throwing them into boiling water 
for a few minutes; they are then removed, the excess of 
moisture is wrung out of them, and they are applied to 
cover the wound. 

If it is desirable, they may be used as antiseptic dress- 
ings by soaking them for a few minutes in a 1 : 1000 or 
1 : 2000 bichloride solution, or in a 5 per cent, carbolic 
solution. This dressing will keep the wound aseptic until 
a more elaborate dressing can be obtained. 

Aseptic or Antiseptic Bandages. Aseptic bandages 
are prepared by tearing or cutting gauze into strips from 
two and a half to three inches in width and forming these 
strips into rollers, which are sterilized by boiling or dry 
heat. They should be used soon after being prepared, or, 
if kept for any time, should be resterilized before being 
used. 



GA UZE DRESSINGS. 141 

Antiseptic bandages may be prepared from bichloride 
or carbolized gauze, but before being used, to render their 
sterilization more complete, may be soaked for a few min- 
utes in a 1 : 1000 bichloride or a 5 per cent, carbolic solu- 
tion. 

Bichloride Cotton. This material is prepared by soak- 
ing absorbent cotton in a 1 : 1000 bichloride solution for 
twenty-four hours, and allowing it to dry, or it may be 
dried in a hot oven; when dry it is packed in jars or in 
air-tight boxes. Several layers of bichloride cotton are 
usually applied over the gauze dressing, as its great ab- 
sorbing power and elasticity make it, when properly pre- 
pared, a most valuable dressing. Borated, carbolized, and 
salicylated cotton prepared in the same manner are also 
frequently employed for similar purposes. 

Sterilized Cotton. Sterilized cotton is prepared by 
placing absorbent cotton, enclosed in perforated metal 
cans, in a steam sterilizer and allowing it to remain for 
several hours. It is used for the same purposes in dress- 
ings as the bichloride cotton. 

Moist Sterilized Gauze Dressings. Moist sterilized 
gauze dressings are prepared by subjecting gauze which 
has been boiled in soda solution to the action of boiling 
water or of steam for thirty minutes. Gauze thus treated 
should be used as soon as prepared. 

Sterilized gauze may also be prepared by putting rolls or 
pieces of gauze, cut from eight to twelve inches square, 
into cylindrical tin boxes, three inches in diameter and 
eight inches in height, with perforated metal covers, and 
covering the gauze at each end of the cylinder with a layer 
of cotton before putting on the covers. The boxes should 
next be placed in a steam sterilizer for an hour or two, and 
when taken out may be kept with safety for some time 
if the cotton coverings are not disturbed. Cotton can be 
sterilized and kept in the same way. 

Dry Sterilized Gauze Dressings. Dry sterilized gauze 
dressings are prepared by cutting gauze into proper lengths 
and packing it loosely in wire cages or perforated metal 
cans, which are next placed in a dry sterilizing-oven for 



142 



MINOR SURGERY. 



several hours, and upon removal it is placed in air-tight 
jars or metal boxes. In using sterilized gauze dressings 
it is safer to have the dressings freshly sterilized immedi- 
ately before each operation. A convenient form of steril- 
izing-oven is shown in Fig. 118. Towels and operating- 
gowns can be sterilized in the same oven. 

Fig. 118. 




Hot-air sterilizer. 

Surgical Operating-bag. For operations in private 
practice the surgeon will find it convenient to have a bag 
or kit containing gauze dressings, bichloride pellets, car- 
bolic acid, alcohol, turpentine, ligatures, sutures, needles, 
syringes, a metal tray in which instruments can be boiled, 
a nest of agate-ware basins, sponges, gauze pads, a sheet 
of rubber cloth, drainage-tubes, and operating-gown. 
These can all be packed in a comparatively small space, 



TREATMENT OF WOUNDS TO SECURE ASEPSIS. 143 

and when the surgeon is called upon to perform any spe- 
cial operation at short notice the instruments required may 
be selected, wrapped in a Canton-flannel scroll, and placed 
in the bag. Much time will be saved by having the mate- 
rials required in operations always in readiness in such a 
bag. 

METHODS AND DRESSINGS EMPLOYED IN THE TREAT- 
MENT OF WOUNDS TO SECURE ASEPSIS. 

To prevent infection of wounds the various chemical 
sterilizers and dressings are employed in different ways, 
and the principal types of dressings are as follows : 

Method by Simple Drying. This method is employed 
in small and not very deep wounds. The edges having 
been brought together by sutures the surface of the wound 
is dusted with powdered iodoform, the serum and blood 
forming with this, as it dries, a scab, which protects the 
wound from infection from without, and repair takes place 
promptly under this scab. Treves employs this method of 
dressing in compound fractures. A pledget of gauze satu- 
rated with iodoform -collodion or tr. benzoin, 5ij; collo- 
dion, 3vj, may be employed instead of powdered iodoform 
in this method of dressing. Dry sterilized gauze and 
cotton dressings may also be employed in this method of 
dressing. 

Method by Drying and Chemical Sterilization. The 
object of this method of dressing is to provide a means of 
sterilizing the blood or serum which escapes from the 
wound, and at the same time to insure the sterilization of 
the air coming in contact with the discharges of the wound. 
It is employed in large or deep wounds, where there is 
always more or less escape of blood or serum, and is 
accomplished by applying a number of layers of subli- 
mate or iodoform-gauze and sublimated cotton over the 
wound. Evaporation not being interfered with, the whole 
dressing becomes hardened, and the wound is surrounded 
by a large antiseptic crust made up of the dressing and 
serum or blood, 



144 MINOR SURGERY. 

Moist Dressings. In this method of dressing the wound 
is covered by layers of moist antiseptic gauze, which are 
kept moist and evaporation prevented by applying over 
them some impervious material, such as mackintosh or 
rubber-tissue. 

Modified Moist Dressing. In using this method the 
wound itself is covered by a piece of protective or rubber- 
tissue; over this is placed the sublimated or iodoform- 
gauze dressing and some layers of bichloride cotton. In 
this way the wound itself is kept in a moist condition 
favoring particularly the organization of blood-clots; the 
external dressings become dry as the discharges which 
have escaped into them evaporate, forming an antiseptic 
crust or covering over the wound. 

Preparation for Aseptic Operation. 

Preparation of Room for Operation. In hospital prac 
tice suitable operating-rooms are provided; in private prac- 
tice, however, the surgeon is often called upon to select a 
room and give directions as to its preparation. A well- 
lighted room should always be selected, and all unneces- 
sary articles of furniture, such as ornaments, pictures, and 
curtains, should be removed. The carpet should be taken 
up, and the floor scrubbed. A few small tables and a large 
wooden table should be placed in the room, having pre- 
viously been dusted and wiped off with a bichloride solu- 
tion. All preparations should be made, if possible, upon 
the day before the operation, as the stirring up of dust 
incidental to the change in furniture in cleaning the room 
on the day of operation immediately before the time set is 
more dangerous than no cleaning of the room whatever, 
since the principal contamination of the wound is likely to 
come from germs contained in the dust. In case of emer- 
gency the floor may be well moistened by sprinkling with 
water to ,lay the dust. The preparation of the room is 
not, in my judgment, a matter that affects the results of 
operations as much as does the exercise of great care in 
regard to aseptic details of the operation itself. 



PREPARATION OF PATIENT. 145 

Preparation of the Patient for Aseptic Operation. 

The patient should be given a general bath the night be- 
fore the operation, and the skin surrounding the site of 
operation should be rubbed over with cotton saturated 
with spirits of turpentine, and should then be thoroughly 
scrubbed with a brush and soap and water; or a soap poul- 
tice may be applied to the part for a few hours before the 
final sterilization with alcohol and bichloride is made. In 
scrubbing the skin a soft brush should be used, since too 
forcible scrubbing may cause irritation or dermatitis. After 
this scrubbing has been continued for a few minutes the 
skin is washed with alcohol, and if turpentine has not been 
used it is better to rub the skin over with ether, then wash 
it with sterilized water and apply to the surface a folded 
towel or gauze dressing saturated with a 1 : 1000 bichloride 
solution; or if a moist dressing is uncomfortable to the 
patient, a few layers of sterilized gauze should be placed 
over the surface and held in place by a bandage. A sim- 
ilar washing and preparation of the seat of operation 
should be made upon the next morning, a few hours be- 
fore the time fixed for operation. 

The skin may also be sterilized by formalin. It should 
first be thoroughly scrubbed with soap and water, and then 
a few layers of gauze saturated with a 1 per cent, solution 
of formalin should be laid over it and covered by an im- 
permeable dressing. The solution should be kept in con- 
tact with the skin for twenty-four or thirty-six hours, the 
compress being changed every tw r elve hours. 

It is well to remember that regions of the body which 
contain hair and numerous sweat-glands, such as the axilla, 
navel, scrotum, groin, and the creases about the joints, are 
those in which micro-organisms grow with the greatest 
activity. All the surrounding hair should be shaved off, 
and if the operation be upon the skull it is well to shave 
the scalp completely. 

Sterilization of the Feet. The feet should be thor- 
oughly washed with soap and water and scrubbed vigor- 
ously with a brush; or a soap poultice should be applied 
to the whole surface of the feet for some hours and held 

10 



146 MINOR SURGERY. 

in position by a bandage. A moist dressing favors the 
separation of the superficial layers of the epidermis, and 
after it has been worn for a few hours it is possible to 
remove a large amount of the latter by the use of the 
brush. After having been thoroughly washed with a 
1 : 1000 bichloride solution they should be wrapped in a 
towel or a few layers of gauze saturated with bichloride of 
mercury solution, 1 : 1000. 

Sterilization of the Vagina. According to Schimmel- 
busch, the best method of sterilizing the vagina is to scrub 
it thoroughly with pads of gauze saturated with green soap 
and water, and after this cleansing, to irrigate it with a 
1:2000 bichloride solution or a 1 per cent, solution of 
kreolin. 

Sterilization of the Bladder. It is impossible to em- 
ploy any method that will sterilize completely the mucous 
membrane of the bladder. The best means we have at 
our disposal at the present time of sterilizing the mucous 
membrane of the bladder consists in irrigating the organ 
frequently with a 10 grain to the ounce solution of boric 
acid in boiled water. 

Sterilization of the Rectum. When an operation is 
to be performed upon the anus and rectum the patient 
should be given a purgative and an enema some hours 
before the operation, to remove any fecal matter which 
may be in the rectum. The region of the anus should be 
disinfected with soap and water and thoroughly scrubbed, 
and after the patient has been anaesthetized the sphincter 
should be well stretched and the rectum irrigated with a 
boric-acid solution. A tampon of sterilized gauze, with a 
string attached, should be packed into the rectum above 
the seat of operation, to prevent the wound from becom- 
ing soiled with feces during the operation. The tampon 
can be removed by means of the string after the operation 
has been completed. 

Sterilization of Instruments. The sterilization of in- 
struments can be accomplished by dry or moist heat; 
they can be placed in a hot-air sterilizer or baked for 
twenty minutes in a hot oven. Sterilization of instruments 



STERILIZATION OF THE HANDS. 147 

by dry heat or baking is not often employed, as it is apt 
to spoil the temper of the steel. Instruments may be ster- 
ilized by the method suggested by Schimmelbusch, now 
almost universally employed, which consists in boiling 
them for fifteen minutes in water to which a tablespoonful 
of washing soda (carbonate of sodium) has been added for 
each quart of water; this prevents the rusting of the in- 
struments, and also makes the water a better solvent for 
any fatty matter which may be upon the instruments, thus 
increasing the sterilizing effect of the heat. If wooden- 
handled instruments are used, which would be injured by 
boiling, they should first be thoroughly scrubbed with soap 
and water and a brush, and after having been rinsed in 
sterilized water they should be placed in a tray and cov- 
ered with 1 : 20 watery solution of carbolic acid, and 
allowed to remain in this solution for at least half an 
hour; before being used they should be transferred to a 
solution of sterilized water, which will prevent the be- 
numbing effect of the carbolic solution upon the surgeon's 
hands. 

Instruments may also be sterilized by formalin; the 
latter is generated by heating pastilles of paraform with 
Schering's formalin lamp. The instruments are placed in 
racks in a metal case, and by burning from 10 to 15 grains 
of paraform the instruments may be rendered sterile in 
fifteen minutes. 

Instruments which fall upon the floor or come in con- 
tact with the clothing of the surgeon or of the patient 
during the operation, should be again sterilized before 
being brought in contact with the wound. 

Sterilization of the Hands. The hands of the sur- 
geon, unless properly sterilized, may be the most efficient 
agents in producing infection of the wound; the region of 
the finger-nails and the inter digital folds are locations where 
germs are particularly abundant. The hands and forearms 
of the surgeons, assistants, and nurses who are to take part 
in the operation may be sterilized by first rubbing them 
with spirit of turpentine, and then thoroughly scrubbing 
them with Castile soap and water, using a nail-brush freely. 



148 MINOR SURGERY. 

Care should be taken that the brush is sterilized. This 
scrubbing should be employed for several minutes; the 
hands are then rinsed to removed the soap, and are soaked 
for two minutes in a 1 : 1000 bichloride of mercury solu- 
tion. If turpentine has not been employed before wash- 
ing with the soap, strong alcohol or ether should be well 
rubbed over the hands before they are immersed in the 
bichloride solution. When the hands have been sterilized 
they should not be brought in contact with anything that 
is not sterile. 

A method of sterilizing the hands which is very satis- 
factory is that employed by Kelly, which consists in wash- 
ing the hands and forearms with soap for ten minutes, and 
then covering them with a warm saturated solution of per- 
manganate of potassium, which stains them a deep ma- 
hogany color; they are then washed in a warm saturated 
solution of oxalic acid until all the permanganate stain is 
removed, and should next be washed in sterilized water to 
remove the oxalic acid which may adhere to the skin. 

Weir recommends the following method of sterilizing 
the hands. After washing them with green soap, put a 
tablespoonful of commercial chloride of lime and an equal 
amount of carbonate of sodium (washing soda) in the hand, 
with enough water to make a paste. Rub this into a thick 
cream, which should be rubbed into the hands until the 
grains of lime disappear and the skin feels cool. The 
hands are then rinsed in sterile water. 

Rubber or Cotton G-loves. Rubber gloves, which may be 
sterilized by washing with soap and water and immersion 
in a 1 : 1000 solution of bichloride of mercury or by boil- 
ing, have recently been employed by surgeons to avoid 
infection of wounds from the hands, as they can be ren- 
dered much more sterile than the skiii of the hands. In 
operations upon septic or infected wounds, the use of rub- 
ber gloves protects the surgeon from infection, in case 
wounds or abrasions are present upon his hands. They 
interfere, however, with tactile sensation, and in delicate 
operations their employment is not satisfactory. 

Cotton or silk gloves, which have been sterilized by boil- 



DETAILS OF ASEPTIC OPERATION. 149 

ing or by dry heat, have been recommended by Mikulicz 
and other surgeons, to be worn during operations. Experi- 
ments, however, have shown that cotton or silk gloves are 
not as safe as those made of rubber. 

Clothing of Surgeon and Assistants. The surgeon 
and his assistants should wear sterilized linen or muslin 
suits, or be provided with gowns with sleeves reaching 
to the elbows, for the protection both of the patient and of 
their clothing. The operating-gown should be made of 
muslin or linen, which can easily be sterilized by boiling 
or heat; a variety of linen known as butcher's linen is very 
serviceable for this purpose. As a matter of additional 
precaution, many surgeons and their assistants wear dur- 
ing the operation closely fitting skull-caps of linen, and 
wear over the nose and mouth a pad composed of a num- 
ber of layers of sterilized gauze to prevent infection of the 
wound by the expired air. The surgeon and assistants 
will often find it conventent to wear under their linen 
gowns India-rubber aprons, to prevent the soiling of the 
clothing by blood or solutions. The nurses should wear 
sterilized linen or muslin operating-gowns and dresses of 
washed goods. An operating-apron may be improvised 
from a clean sheet folded so as to be one and a half yards 
in width and from five to six feet in length, by turning in 
about ten inches of one end of the sheet over the upper 
part of the chest aud placing a strip of bandage in this 
fold, which should be secured around the neck, and tied 
by a second strip of bandage over the sheet at the waist. 

Details of an Aseptic Operation. The patient being 
prepared for operation as described, and having been anaes- 
thetized, is placed upon the operating-table, the surgeon, 
assistants, and nurses also being prepared for the operation 
as previously described. If the operation be one upon 
the face, neck, or chest, it is well before the dressings 
covering the seat of operation are removed to cover the 
patient's hair with a towel or handkerchief bandage made 
of several layers of sterilized or bichloride gauze. The 
portions of the patient's body which it is not necessary to 
expose in the operation should be covered with a woollen 



150 MINOR SURGERY. 

blanket, and this covered with a sterilized sheet. Some 
surgeons prefer to have the patient wear a sterilized gown, 
which is ripped or cut to expose the part to be operated 
upon. The region of the wound and the operating-table 
are next protected with sterilized towels or cloths. The 
surgeon having assigned the assistants and nurses their 
duties, the dressing is removed from the part to be oper- 
ated upon, and the operation is begun. Hemorrhage is 
controlled during the operation by the use of haemostatic 
forceps, and sterilized gauze pledgets are employed to keep 
the wound free from blood. When the operation is com- 
pleted, the vessels are ligated, the haemostatic forceps are 
removed, and the wound is dried with gauze pledgets. 
If, for any reason, the surgeon deems it advisable to irri- 
gate the wound, it may be done with hot sterilized water 
or with sterilized salt solution. If the surgeon decides 
that drainage is not necessary, the deeper parts of the 
wound may then be brought together by buried sutures of 
catgut or silk, and the edges of the superficial wound next 
approximated by sutures of catgut, silk, or silkworm-gut. 
If the surgeon decides to use drainage, before closing the 
wound, a few strands of catgut, a strip of sterilized gauze, 
a tent of rubber tissue, or a rubber drainage-tube is 
introduced into the deepest portion of the wound and 
brought out at its most dependent part. The wound is 
then dressed with a number of loose masses of sterilized 
gauze placed so as to cover the wound and extend beyond 
it in all directions, aud these are covered by a number 
of layers of sterilized gauze. Over the gauze dressing are 
placed a few layers of sterilized cotton, extending on all 
sides well beyond the gauze, and the dressings are held 
in place by a sterilized gauze bandage. The dressings 
should be voluminous; it is always a mistake to apply 
scanty dressings. In redressing the wound the same care 
should be exercised as regards asepsis as was observed at 
the primary dressing. 

Details of an Antiseptic Operation. The region of 
the wound being previously sterilized and the patient 
being anaesthetized and placed upon the table, the cloth- 



DETAILS OF AN ANTISEPTIC OPERATION. 151 

ing is so arranged as to expose freely the part to be oper- 
ated upon; the clothing or the skin surrounding this region 
is next covered with towels wet with a 1 : 1000 bichloride 
solution. If any considerable surface of the patient's body 
is covered by these towels, to avoid chilling the surface and 
adding to the shock which naturally follows the operation, 
they should be wrung out in a hot bichloride solution, and 
should be replaced as they become cold by hot towels pre- 
pared in the same manner. The patient being ready for 

Fig. 119. 




Irrigating apparatus. (Esmarch.) 



operation, the surgeon should assign the assistants and 
nurses their duties, and having previously sterilized their 
hands and forearms, and again immersed them in the bi- 
chloride solution, the operation is begun. 

During the operation the wound is irrigated frequently 
with a 1 : 2000 bichloride solution, which may be allowed 
to run over the wound, or be applied by means of a 
syringe or irrigating apparatus (Fig. 119), and the hands 
of the surgeon and assistants should also be washed in this 
solution at not too long intervals. In prolonged opera- 
tions, or in those in which a large wound is made, I think 



152 MINOR SURGERY. 

it is especially important that the irrigating solutions 
should be used as warm as can be comfortably borne by 
the hands of the surgeon; warm solutions, it has been 
shown by recent investigations, possess a greater germi- 
cidal power than those of the same strength when used 
cold, and they also possess the advantage of preventing 
the chilling of the patient, and thus diminish the shock of 
the operation. 

Hemorrhage during the operation is controlled by the 
use of haemostatic forceps, which are applied to the bleed- 
ing vessels, or the vessels may be ligatured as they are 
divided. After the operation has been completed, and all 
hemorrhage has been controlled, the wound is thoroughly 
irrigated with a 1 : 2000 bichloride solution. 

The next step is to provide for drainage; this may be 
disregarded in small superficial wounds, but in a wound 
of any considerable size or depth it is safer to provide free 
drainage. This is accomplished by the use of perforated 
rubber drainage-tubes, or a number of strands of catgut, 
or strips of iodoform or bichloride gauze. 

The rubber tube may be laid in the wound, the ends 
being allowed to extend from the extremities of the wound, 
or it may be so introduced that one end of the tube rests in 
the deepest part of the wound and the other extremity is 
brought out of the wound at its most dependent portion; 
in large or irregularly shaped wounds a number of tubes 
may be required to secure free drainage. The ends of the 
drainage-tubes are transfixed with safety-pins which have 
been sterilized and should next be cut off close to the pins 
so as to be as nearly as possible flush with the skin. 

The wound being closed by sutures, a final irrigation of 
its deepest parts should be made, by injecting a stream of 
bichloride solution, 1 : 2000, into the end of the drainage- 
tube. The external surface of the wound and the skin 
for some distance surrounding it should next be washed 
with a 1 : 2000 bichloride solution, and a piece of protec- 
tive, a little longer and wider than the wound, is next 
dipped in a bichloride or carbolic solution and placed over 
it. The use of this strip of protective over the wound is 



MOIST METHOD OF DRESSING. 153 

only important if it is desired to keep the wound moist, 
in order to obtain organization of the blood-clot, otherwise 
it need not be employed. Over this is laid the deep dress- 
ing, which consists of a pad of bichloride gauze from eight 
to sixteen layers in thickness, and large enough to overlap 
the wound two or three inches in all directions. This 
should be dipped in a 1 : 2000 bichloride solution, and 
wrung out as dry as possible before being applied. The 
superficial gauze-dressing is next applied, and consists of 
sixteen layers of gauze, which should be large enough to 
extend from three to six inches beyond the wound in all 
directions; this gauze is applied dry. Over the superficial 
gauze-dressing there is next applied a number of layers of 
bichloride cotton, so arranged as to extend a little beyond 
the margin of the superficial gauze-dressing. These dress- 
ings are next secured in position by the application of a 
gauze bandage, which is prevented from slipping by the 
introduction of a few safety-pins. 

Iodoform, carbolized, or any other variety of medicated 
gauze, may be used in the place of the bichloride gauze in 
this method of dressing. 

In this method of dressing no mackintosh or rubber- 
tissue is employed, outside of the superficial gauze-dress- 
ing; the discharges from the wound are disseminated 
through the dressing and become dry by evaporation, and 
the dressing forms an antiseptic scab which covers and 
surrounds the wound. 

Moist Method of Dressing. If, for any reason, it is 
desired to adopt the moist method of dressing, a piece of 
mackintosh or rubber-tissue larger than the superficial 
gauze-dressing is placed over it, and over this are placed 
a few layers of bichloride-cotton, care being taken to see 
that the layers of cotton overlap the mackintosh or rubber- 
tissue by a few inches; the application of an antiseptic 
gauze-bandage then completes the dressing. On the re- 
moval of this dressing the gauze will be generally found 
to be soaked with the discharges from the wound, and in 
a moist condition. The disadvantage of this variety of 
dressing is that there is apt to be more irritation of the 






154 MINOR SURGERY. 

skin set up by the bichloride-gauze when kept moist than 
when applied in the manner of a dry dressing. 

Redressings of the Wound. The redressing of a 
wound which remains aseptic need not be made for some 
days; if the temperature remains normal or a little above 
this point, and the patient exhibits no unfavorable consti- 
tutional symptoms, and the dressing is comfortable to the 
patient, it need not be disturbed for a week or ten days; 
at the expiration of this time it is well to examine the 
wound and to remove the drainage-tube if drainage has 
been used, and to remove a portion or all of the sutures if 
the superficial parts of the wound are firmly healed. 

In redressing a wound in which the antiseptic method was 
employed, at the end of a week or ten days, to prevent any 
possible infection, as much care should be exercised as in 
the original dressing of the wound. The patient's clothes 
should be removed so as freely to expose the dressing, and 
a rubber cloth should be placed under the patient so as to 
protect the bed, and the clothing and skin in the region of 
the wound should be protected by towels wrung out in a 
1 : 1000 bichloride solution. The surgeon should wash his 
hands and immerse them in a 1 : 1000 bichloride solution 
before removing the dressings. The bandage retaining 
the dressing should be divided with bandage-scissors and 
the gauze should be removed layer by layer, and when the 
deep dressing is removed care should be taken to see that 
the drainage-tubes are not pulled upon if they are adher- 
ent to the dressing; the protective should next be removed, 
and the surface of the wound should be irrigated with a 
1 : 2000 bichloride solution. If the wound is found asep- 
tic, the drainage-tube may be removed, aud the superficial 
wound should next be irrigated with bichloride solution. 
If the wound is healed, the sutures may be removed at 
this dressing; but if the wound has been an extensive or 
deep one, it may be well to remove only a portion of the 
sutures; if catgut sutures have been employed, they need 
not be removed. The surface of the wound is next irri- 
gated with a 1 : 2000 bichloride solution, and deep and 
superficial gauze dressings are applied as previously de- 



BEDBfiSSING OF THE WOUND. 155 

scribed, and covered with layers of bichloride-cotton, and 
the whole dressing is secured by the application of an anti- 
septic bandage. If the wound remains aseptic, the dress- 
ings need not be changed for a week or ten days, and at 
this time the wound will usually be found healed, so that 
further dressings are not required. 

In the redressing of a wound in which the aseptic method 
was employed, the use of germicidal solutions is omitted, 
and the wound is redressed with sterilized gauze and cotton. 

If, however, the wound is not running the typical course 
of an aseptic wound, constitutional symptoms will be devel- 
oped, as evidenced by a rise in the temperature and pulse- 
rate and other constitutional disturbances. In this event 
the wound should be redressed as soon as possible, and if 
the cause of the disturbance can be found, it should be 
removed; for instance, hemorrhage may have taken place 
into the wound, and the blood not being able to escape 
through the drainage-tubes may have caused so much dis- 
tention of the wound that the vitality of the skin cover- 
ing the wound is threatened, or the sutures may be found 
to be causing irritation, or suppuration may be found to be 
present. 

If, on exposure of the wound, it is found that it is dis- 
tended with blood-clots and blood is escaping from the 
wound, the sutures should be removed, the clots should be 
turned out, and the bleeding vessel or vessels should be 
sought for and ligatured, and the wound, after a thorough 
irrigation with 1 : 2000 bichloride solution, should be 
drained and closed with sutures, and dressed as previously 
described. 

If, however, on exposure of the site of the operation, 
and upon the removal of a portion or all of the sutures, 
the wound is found distended with a blood-clot, and no 
evidence of hemorrhage at the time exists, or of suppura- 
tion in the wound, the clot may be allowed to remain in 
place, and the wound should be redressed as in the original 
dressing, trusting to the organization of the blood-clot if 
it has remained aseptic. If the patient's condition im- 
proves after the dressing, and the temperature and pulse- 



156 MINOR SURGERY. 

rate become normal, it is an indication that the wound is 
still aseptic, and it need not be redressed for some days. 

If, on the other hand, examination of the wound shows 
that the drainage is insufficient, or that the drainage-tubes 
are occluded by blood-clots, these should be removed by 
washing out the tubes with a 1 : 2000 bichloride solu- 
tion by means of a syringe, and introducing additional 
drainage-tubes, if it is deemed necessary; the wound should 
then be redressed. 

When it is found on examination of the wound that 
suppuration is present, it should be thoroughly irrigated 
through the drainage-tubes with a 1 : 2000 bichloride solu- 
tion, and after thorough irrigation it should be redressed, 
and, if the patient's constitutional symptoms improve, it 
may be assumed that the wound has been rendered aseptic. 

Aseptic or Antiseptic Treatment of Infected Wounds. 
It often happens that the surgeon is called upon to treat a 
wound which is septic when it comes under his care, as 
evidenced by the inflamed state of the wound, inflamma- 
tion of the lymphatic vessels and skin, foul discharges and 
sloughing of the tissues, and the coexistent constitutional 
symptoms of sepsis. In such a case it would at first sight 
appear that the surgeon or his assistants could not intro- 
duce any material of infection worse thau that which 
already existed in the wound, but he should bear in mind 
the fact that it is possible to introduce a new form of 
infection in addition to that already existing. With this 
possibility in view he should observe the same precautions 
as regards the sterilization of his hands, the region of the 
wound, the instruments, and dressings, as he would employ 
in treating a perfectly fresh wound. 

Recent investigations, however, have shown that the 
germs in abscesses are to a great extent dead, and that the 
pus-formation is largely due to the irritation caused by 
their products. In view of these facts, it would seem 
that the most important part of the treatment of infected 
wounds is thorough drainage. It is a question whether 
the micro-organisms in the walls of infected cavities or 
sinuses can be destroyed by antiseptic irrigation. Some 



TREATMENT OF INFECTED WOUNDS. 157 

surgeons recommend active treatment, both mechanically 
and by the use of germicidal solutions, while others are 
satisfied simply to secure free drainage, and if irrigation 
is necessary they do not employ strong germicidal fluids, 
but use simply sterilized water or sterilized salt solution. 
I prefer to employ the antiseptic method in dealing with 
infected wounds, and can recommend the following plan. 
The skin surrounding the wound for some distance should 
be wiped over with spirits of turpentine and carefully 
scrubbed with soap and water, and should next be Avashed 
with a 1 : 1000 bichloride solution; the wound itself should 
next be washed with peroxide of hydrogen and a 1 : 1000 
bichloride solution. With forceps and curette any dirt or 
sloughing tissue should be removed; then the wound again 
washed with peroxide of hydrogen and douched with a 
1 : 2000 bichloride solution. The wound should then be 
dried with gauze pledgets and dusted with iodoform and 
loosely packed with strips of iodoform gauze. If from 
the appearance of the tissues the surgeon has reason to 
think that the infection has passed beyond the reach of the 
curette or scissors, he may swab the surface of the wound 
over with a solution of chloride of zinc, 30 grains to the 
ounce of water. Pure carbolic acid may be used, and is 
recommended by some surgeons, for the same purpose as 
chloride of zinc, but the toxic action of carbolic acid causes 
its employment to be attended with some danger. Free 
drainage being secured by the introduction of a few strips 
of iodoform gauze, the wound is dressed with a voluminous 
dressing of bichloride gauze and bichloride cotton. No 
attempt, as a rule, should be made to bring together the 
edges of such a wound by the introduction of sutures. 
In the dressing of infected wounds, when the discharges 
are ropy or viscid they are not well absorbed by dry dress- 
ings, and in this class of wounds it is, therefore, often of 
advantage to employ moist antiseptic dressings. By this 
method of treatment it is often possible to convert a septic 
wound into an aseptic one, and have rapid improvement 
follow both in the local condition of the wound and in the 
constitutional condition of the patient. 



158 MINOR SURGERY. 

MATERIALS USED IN SURGICAL DRESSINGS. 

Lint. This material is employed in surgical dressings, 
and is of two varieties : the domestic lint, which consists 
of pieces of old linen or muslin which have been thor- 
oughly washed or boiled and then dried, or the surgical 
lint which resembles Canton flannel in appearance; the 
latter is the best material, as it has a greater absorbing 
capacity. 

Lint is used as a material on which unctuous prepara- 
tions are spread in the dressing of wounds, and is also 
employed as a material for saturating with the various 
solutions which are used in wet dressings, such as lead- 
water and laudanum; the lint, after being saturated with 
the solution, is covered with rubber-tissue or oiled silk 
when applied, to prevent too rapid evaporation of the solu- 
tion. It is also one of the best materials from which to 
construct the compresses employed in the treatment of 
fractures. 

Paper-lint. This is made from old rags or wood pulp, 
has great absorbiug power for fluids, and may be used as 
a substitute for surgical lint in the application of wet 
dressings to surfaces when the skin is unbroken. 

Oakum. This material, made from old tarred rope, 
was formerly much employed in the dressing of wounds 
before the introduction of the antiseptic method of wound- 
treatment. From its elasticity it is found to be an excel- 
lent material for padding splints or other surgical appli- 
ances. It is also employed in the form of pads to place 
under patients to relieve portions of the body from press- 
ure, or to absorb discharges which soak through the dress- 
ings. A mass of oakum which has been well teased out 
and wrapped in a towel forms an excellent pillow on which 
to support a stump. 

Cotton. Cotton is now employed in surgical dressings 
principally as a material to pad splints or to relieve salient 
parts of the skeleton from pressure in the application of 
splints or bandages; for instance, in the application of the 



ABSORBENT COTTON. 159 

plaster-of-Paris bandage, the bony prominences are gener- 
ally covered by small masses of cotton; it possesses but 
little absorbent power unless used in the form of absorbent 
cotton, and is not much employed in surgical dressings 
except for the purposes mentioned above. 

Absorbent Cotton. This material is prepared from 
ordinary cotton, which is boiled with a strong alkali to 
remove the oily matter which it contains. When so pre- 
pared it absorbs liquids freely, and by reason of its great 
absorbing capacity it is largely employed in surgical dress- 
ings. A small mass of sterilized absorbent cotton wrapped 
upon the end of a probe is now generally employed to 
make applications to wounds, and has taken the place of 
the sponge or brush which was formerly employed for this 
purpose. On account of its cheapness, after one applica- 
tion it can be thrown away and a new piece can be used, 
and thus the danger of carrying infection from one wound 
to another by the applicator is abolished. It is largely 
employed in gynecological practice for making applica- 
tions to the female genital organs. 

It may be impregnated with various antiseptic sub- 
stances, such as the bichloride of mercury, carbolic acid, 
boric acid, and salicylic acid, and when thus treated forms 
the bichloride, carbolized, borated, and salicylated cotton so 
much employed in antiseptic dressings. 

Wood-wool. Wood-wool made from wood-pulp, such 
as is employed in the manufacture of paper, is also fur- 
nished in the shape of lint, sponges, and pads, and may 
beused for the same purposes as the ordinary surgical 
lint. 

Oiled Silk or Muslin. These materials are employed 
as an external covering for moist dressings to prevent 
rapid evaporation from the dressings; they form excellent 
materials for this purpose, but as they are quite expensive 
their use is limited. 

Waxed or Paraffin Paper. This dressing is prepared 
by passing sheets of tissue-paper through melted wax or 
paraffin, and then allowing them to dry. Paper thus treated 
forms an excellent and cheap substitute for oiled silk or 



160 MINOR SURGERY. 

muslin, and may be employed for the same purpose for 
which the latter materials are used. 

Rubber-tissue. This material, which is prepared by 
rubber manufacturers, consists of rubber run out into very 
thin sheets. It has a glazed surface, is very pliable, and 
at the same time strong, forming, therefore, a cheap and 
satisfactory substitute for oiled silk, and is employed for 
the same purposes. 

Parchment Paper. This paper is prepared so as to 
render it water-proof; it is employed in surgical dressings 
for the same purposes as oiled silk and rubber tissue. 

Compresses. Compresses are prepared by folding pieces 
of lint, muslin, linen, or gauze upon themselves, so as to 
form firm masses of variable sizes; oakum or cotton may 
also be used to form compresses. Compresses are em- 
ployed to make pressure over localized portions of the 
body, as in the treatment of fractures, or to make press- 
ure upon vessels for the control of hemorrhage. 

Tampon. A tampon is a form of compress which is 
employed in cavities to make pressure, to control hemor- 
rhage, or to apply various solutions or powders to the 
surface of the cavity. Tampons used to control hemor- 
rhage are generally made of strips of bichloride, iodo- 
form or sterilized gauze. In applying these, the strips of 
gauze are packed into the cavity, and when the latter is 
full a compress is applied superficially and held in place 
by a bandage. The application of a tampon to the vagina 
is a favorite method of controlling uterine hemorrhage. 

Glycerin Tampon. This is made by pouring half an 
ounce of glycerin on a piece of cotton or wool, and then 
turning up the ends and securing them by a string, one 
end of which is allowed to remain long enough to hang 
from the vagina, to facilitate its removal; it is a favorite 
application to the os uteri. 

Tent. This consists of a small portion of lint, oakum, 
muslin, or sterilized or antiseptic gauze rolled up into a 
conical shape, which is employed to keep wounds open and 
to facilitate the escape of discharges. 

Retractors. Retractors are made by taking a piece of 






PLASTERS. 



161 



muslin four inches wide and twelve to eighteen inches in 
length and splitting it as far as the centre, thus making a 
two-tailed retractor (Fig. 120). A three-tailed retractor is 
made in the same way, except that the muslin is slit twice 
instead of once (Fig. 121). Eetractors are used to retract 
the soft parts in amputation, to prevent their injury by the 
saw in the division of the bones. When one bone is 
sawed a two-tailed retractor is used, and when two bones 
are sawed a three-tailed retractor is employed. 



Fig. 120. 



Fig. 121. 








Two-tailed retractor. 



Three-tailed retractor. 



Plasters. The varieties of plaster which are most com- 
monly employed in surgical dressings are adhesive or resin 
plaster, isinglass plaster and rubber adhesive plaster. 

Before using any of these plasters upon parts which are 
covered by hairs, the latter should be removed by shav- 

11 



162 MINOR SURGERY. 

ing, otherwise traction upon them, if the plaster be used 
for the purpose of extension, will cause the patient dis- 
comfort, and unnecessary pain will also be inflicted at the 
time of its removal. 

Resin Plaster. This plaster, which is machine-spread, is 
one of the most widely employed plasters in surgical 
dressings ; the spread surface is covered with a layer of 
tissue-paper, which should be removed before it is used ; 
it is cut into strips of the required width and length, and 
the strips should be cut lengthwise from the roll of plas- 
ter, as the cloth upon which it is spread stretches more 
transversely than in a longitudinal direction. When 
heated and applied to the surface it holds firmly; it is 
prepared for application by applying the unspread side to 
a vessel containing hot water, or it may be passed rapidly 
through the flame of an alcohol lamp. 

This is the variety of plaster which is generally used in 
making the extension-apparatus for the treatment of frac- 
tures, for strapping the chest in fractures of the ribs and 
sternum, for strapping the pelvis in cases of fractures of 
the pelvic bones, and for strapping the breast, the testicle, 
ulcers, or joints. 

Swan's-down Plaster. This plaster is much the same as 
resin plaster, but is spread upon a heavier material, and is 
an excellent plaster to use for an extension-apparatus, 
where it is to be worn for a long time. 

Rubber Adhesive Plaster. This plaster is made by spread- 
ing a preparation of India-rubber on muslin, and has the 
advantage over the ordinary resin plaster that it adheres 
without the application of heat. It is employed for the 
same purpose as resin plaster, but when applied continu- 
ously to the skin it is apt to produce a certain amount of 
irritation, and for this reason when it is to be continuously 
applied for some time, as in the case of an extension-appa- 
ratus, it is not so comfortable a dressing as that made from 
resin plaster. 

Isinglass Plaster. This plaster is made by spreading a 
solution of isinglass upon silk or muslin, and it has been 
found a most useful dressing in the treatment of superficial 



STRAPPING. 163 

wounds. It is made to adhere to the surface by moisten- 
ing it, and when used in the treatment of wounds it 
should be moistened with an antiseptic solution. The 
best variety is spread on mnslin, and when properly ap- 
plied adheres as firmly and possesses as much strength as 
the ordinary resin plaster. 

Soap Plaster. Soap plaster for surgical purposes is pre- 
pared by spreading empfastrum saponis upon kid or chamois. 

It is not employed for the same purposes as the resin or 
rubber plaster, as it has little adhesive power, and is used 
simply to give support to parts or to protect salient por- 
tions of the skeleton from pressure. It is found to be a 
most useful dressing when applied over the sacrum in 
cases of threatened bedsores, and may be applied for the 
same purpose to other parts of the body where pressure- 
sores are apt to occur. 

In the treatment of sprains of joints a well-moulded 
soap-plaster splint secured by a bandage will often be 
found a most efficient dressing, and in the treatment of 
fractures the comfort of the patient is often materially 
increased by applying small pieces of soap plaster over 
the bony prominences, upon which the splints, even when 
well padded, are apt to make an undue amount of pressure. 

Strapping. 

This consists in applying pressure to parts by means of 
strips of plaster firmly applied; it is a procedure often 
employed in surgical practice. 

Strapping the Testicle. In strapping the testicle 
strips of resin plaster are usually employed; a dozen or 
more strips one-half an inch wide and twelve inches in 
length will be required. 

The scrotum should be first washed and shaved, and the 
surgeon next draws the skin over the affected organ tense 
by passing the thumb and finger around the scrotum at 
its upper portion, making circular constriction; a strip of 
muslin is passed in a circular manner around the skin of 
the scrotum above the organ, and is tightly drawn and 



164 



MINOR SURGERY. 



secured by passing around it a strap of plaster which has 
been heated; this isolates the part and prevents the other 
straps from slipping. Straps are now applied in a longi- 
tudinal direction, the first strap being fastened to the 
circular strap aud carried over the most prominent part 
of the testicle, and then carried back to the circular strap 
and fastened. A number of these straps are applied in 
an imbricated manner until the skin is covered (Fig. 122), 
and the dressing is completed by passing transverse straps 
around the testicle from its lowest portion to the circular 
strap; care should be taken to see that no portion of the 
skin is left uncovered. 

Fig. 122. 





Strapping the testicle. (Smith.) 



Strapping the testicle is employed with advantage in the 
subacute stage of orchitis or epididymitis; as the swelling 
of the testicle diminishes the straps become loose, and the 
part will require re-strapping. It will also be found a 
useful means of applying pressure to the scrotum after the 
injection-treatment of hydrocele. 

Strapping of the Chest. To strap one-half of the 
chest, strips of resin plaster two and a half inches wide, 
and long enough to extend from the spine to the median 
line of the sternum, are required — eighteen to twenty 
inches in length. . The first strap is heated aud one ex- 
tremity is placed upon the spine opposite the lower portion 
of the chest; it is then carried over the chest, and its other 
extremity is fixed upon the skin in the median line of the 
sternum. Straps are next applied from below upward in 
the same manner, each strap overlapping one-third of the 




STRAPPING OF ULCERS. 165 

preceding one, until the axillary fold is reached (Fig. 123); 
a second layer of straps may be applied over the first, if 
additional fixation is desired, or a few oblique straps may 
be employed. 

Adhesive straps applied in this manner very materially 
limit the motion of the chest-wall upon the affected side, 
and are frequently employed in the 
treatment of fractures and disloca- FlG - 123 - 

tions of the ribs, in contusions of the 
chest, and in cases of plastic pleurisy 
when the motions of the chest-wall 
are extremely painful to the patient. 

Strapping of Ulcers. To strap 
ulcers of the leg, strips of resin 
plaster one and a half inches wide, 
and long enough to extend two- 
thirds of the distance around the 
limb, are required. The ulcer strapping the chest. 
should be thoroughly cleansed, and 

the skin surrounding it should be well dried; the first strap, 
being heated, is applied transversely to the long axis of 
the leg about two inches below the ulcer, and is carried 
two-thirds of the distance around the limb; another strap 
is applied to a corresponding point of the skin above this 
one, so that it overlaps one-third of the strap first applied, 
and it is carried two- thirds of the way around the limb. 
Additional straps are thus applied until the ulcer is cov- 
ered in, and the straps are carried several inches above 
the ulcer. (Fig. 124.) Strapping of ulcers may also be 
accomplished by using narrow straps of plaster one and a 
half inches in width. The ends of two straps are placed 
upon the limb some distance below the ulcer and the straps 
are brought up and made to cross each other so as to draw 
the tissues toward the point of crossing; a number of im- 
bricated straps are applied in this way until the parts are 
sufficiently covered in and supported (Fig. 125). Care 
should be taken to see that the straps are so applied as 
not to meet or cover the entire circumference of the limb, 
as by so doing injurious circular compression might result. 



166 



MINOR SURGERY. 



Chronic ulcers upon other portions of the body may be 
strapped in the same manner. 

Strapping of leg ulcers is usually reinforced by the ap- 
plication of a firmly applied spiral reversed or spica- 
baudage of the lower extremity. 



Fig. 124. 




Strapping an ulcer of the leg. 



Strapping of ulcers of the leg applied in the manner 
described will be found a most satisfactory method of 
treating chronic ulcers in this location in patients who 
have to work during the course of treatment; the straps 
need only be removed at intervals of a week ; and if well 



STRAPPING OF JOINTS. 



167 



applied, the dressing is generally a comfortable one to the 
patient. 



Fig. 125. 



; 




Strapping an ulcer of the leg. 

Strapping of Joints. Strips of resin plaster two inches 
in width and long enough to extend two-thirds around the 
joint are required. The first strap is applied a few inches 
below the joint, and straps are then applied over this, each 
strap covering iu two-thirds of the preceding one until the 
joint is covered in and the dressing extends a few inches 
above the joint. 

Strapping will be found a satisfactory dressing in the 



168 MINOR SURGERY. 

treatment of sprains of joints in their acute or chronic 
state. 

Strapping the Ankle-joint. In applying strapping in 
sprains of the ankle or tarsal-joints, strips of rubber adhe- 
sive plaster one and a half inches in width and eighteen 
inches in length are required. The first strap is started 
at the junction of the middle and upper part of the leg, 
either upon the inner or the outer side, and applied closely 

to the edge of the 
FlGl26 - tendo Achillis, and 

carried across the 
sole of the foot to 
the base of the great 
or little toe; several 
of these straps are 
applied, covering in 
the inner or outer 
surface of the ankle. 
A strap is nex t placed 
with its middle at 
the point of the heel, 
the ends being car- 
ried to a point on 
the foot at the junc- 
tion of the metatar- 
sal bones and the 
tarsus; a number of 
these ascending 
straps are applied, 
alternating with the 

Strapping applied to ankle-joint. Vertical straps. Un- 

til the ankle-joint is 
covered in. These straps should not be applied so as to 
meet in front of the foot or ankle and make circular con- 
striction (Fig. 126). After the ankle has been strapped 
as above described, the foot and ankle are covered with a 
gauze bandage, and the patient is allowed to walk upon 
the injured foot. 

Strapping of a Carbuncle. To strap a carbuncle strips 







POULTICES. 169 

of resin plaster one to one and a half inches in width are 
required; these straps are applied at the margin of the 
swelling and are laid on concentrically until all except the 
central portion is covered. If a number of openings exist, 
the straps are so placed as not to cover these. Strapping 
applied in this manner in the treatment of carbuncle is 
often a comfortable dressing for the patient, and at the 
same time the concentric pressure favors the extrusion of 
the slough. 

Poultices. 

This form of dressing was formerly much employed in 
the treatment of inflammatory conditions and injuries as 
a means of applying heat and moisture to the part at the 
same time, and although the use of poultices is now very 
much restricted since the introduction of the antiseptic 
method of wound-treatment, yet I think there are still 
conditions in which their employment is both useful and 
judicious. 

They are often employed with advantage in inflamma- 
tory affections of the chest and of the abdominal organs, 
and in inflammatory affections of the joints and of bone, 
combined with rest, their action is most often satisfactory. 

They constitute a form of dressing which is conducive 
to the comfort of the patient in cases of deep suppuration 
by their relaxing effect upon the tissues, and their previous 
use does not prevent the surgeon from using all aseptic 
precautions in the opening and drainage of these abscesses, 
and the employment of aseptic or antiseptic dressings in 
their subsequent treatment. 

Flaxseed Poultice. This poultice is prepared by adding 
first a little cold water to ground flaxseed, and then boiling 
and stirring it until the resulting mixture is of the consist- 
ency of thick mush. A piece of muslin is next taken 
which is a little larger than the intended poultice, and 
this is laid upon the surface of a table and with a spatula 
or knife the poultice-mass is spread evenly upon it from 
one-quarter to one-half an inch in thickness; a margin of 
the muslin of one or one and a half inches is left, which 



170 MINOR SURGERY. 

is turned over after the poultice is spread, and serves to 
preveut it from escaping around the edges when applied. 
The surface of the poultice may be thinly spread over 
with a little olive oil, or may be covered with a layer of 
thin gauze to prevent the mass from adhering to the skin. 

It is next applied to the surface of the skin and is cov- 
ered with a piece of oiled silk, rubber-tissue, or waxed 
paper, and held in position by a bandage or a binder. 

Soap Poultice. This is made by saturating a number 
of layers of gauze in a mixture of one part of green soap to 
six parts of water. It is then applied to the surface and 
covered with oiled muslin or waxed paper. It may be 
employed as a primary dressing for some hours to the feet 
or other parts of the body where the epidermis is thick, 
before sterilizing these parts before operations. 

Starch Poultice. This poultice is prepared by mixing 
starch with cold water until a smooth, creamy fluid results; 
boiling water is then added, and it is heated until it be- 
comes clear and has about the same consistency as the 
starch used for laundry purposes. When sufficiently cool 
it is spread upon muslin, applied to the part, and covered 
with oiled silk or waxed paper. This variety of poultice 
is principally useful in the treatment of diseases of the 
skin, especially those of the scalp accompanied by the for- 
mation of scabs or crusts, to facilitate their removal and 
to afford a clean surface for the application of ointments 
or wet dressings. 

Fermenting Poultice. This poultice may be prepared 
by adding yeast, two tablespoonfuls, to a mixture of flax- 
seed with hot water, making a thin poultice-mass, and 
allowing it to stand for a few hours in a warm place; it 
rises and becomes light, and is then spread upon muslin 
and applied as required. A few ounces of porter or a 
piece of yeast-cake may be used as a substitute for the 
yeast in preparing this poultice; animal charcoal may 
also be added to it to increase its disinfectant power. 
This poultice was formerly used as an application to gan- 
grenous parts to hasten their separation and to diminish 
the odor arising from the necrosed tissues. 



IRRIGATION. 171 

Antiseptic Poultice. This is prepared by soaking a pad 
of sterilized gauze in hot bichloride or carbolic solution 
and wringing it out to remove the excess of fluid. It is 
next applied to the part and covered with oiled silk or 
rubber-tissue, which may be held in place by a bandage. 
Such a dressing will absorb a considerable amount of 
discharge. 

Hot Fomentations. Hot fomentations are employed to 
keep up the vitality of parts which have been subjected 
to injury, as seen in severe contusions resulting from rail- 
way or machinery accidents; also to combat inflammatory 
action. Gauze, several layers in thickness, or surgical lint 
should be soaked in sterilized water having a temperature of 
120° ; these are wrung out, placed over the part, and covered 
with waxed paper or rubber-tissue; a second cloth should 
be placed in the hot water, ready to apply as soon as the 
first-applied cloth begins to cool, and so by continuously 
reapplying them the part is kept constantly covered by a 
hot dressing. The use of these hot fomentations may in 
many cases require to be continued for hours before the 
desired result is obtained. Hot compresses applied in this 
manner are frequently employed in treating inflammatory 
conditions of the eye, and are also of the greatest service 
in keeping up the vitality of parts which have been sub- 
jected to severe injury interfering with their blood-supply. 
I have seen contused limbs, which were cold and seemed 
to be doomed to gangrene by reason of diminished blood- 
supply, have their temperature and circulation restored by 
the patient and persistent use of this dressing. After the 
vitality of such a part is restored it should be covered with 
cotton and a flannel bandage and surrounded by hot- water 
bags or hot-water cans. 

Irrigation. 

This may be accomplished by allowing the irrigating 
fluid to come in contact with the wound or inflamed part, 
immediate irrigation, or by allowing the cold or warm fluid 
to pass through rubber tubes which are in contact with or 



172 



MINOR SURGERY. 



surround the part; the latter method is known as mediate 
irrigation. 

Immediate Irrigation. In employing immediate irri- 
gation in the treatment of wounds or inflammatory con- 
ditions, a funnel-shaped can with a stop-cock at the bottom, 
or a bucket, is suspended over the part at a distance of a 



Fig. 127. 




Apparatus for continuous irrigation. (Esmarch.) 



few inches (Fig. 127), or a jar with a skein of thread or 
lamp-wick arranged to act as a siphon may be employed 
(Fig. 128). The can or jar is filled with water, and this 
is allowed to fall drop by drop upon the part to be irri- 
gated, which should be placed upon a piece of rubber 



IMMEDIATE IRRIGATION. 



173 



sheeting so arranged as to allow the water to run off into 
a receptacle so as to prevent the wetting of the patient's 
bed. The water employed may be either cold or warm, 
in accordance with the indications in special cases. If it 
is desired to make use of antiseptic irrigation, the water 
is impregnated with carbolic acid or bichloride of mer- 
cury; a 1 : 5000 to 1 : 10,000 bichloride solution, or a 
1 : 60 carbolic acid or acetate of aluminum solution being 
frequently employed with good results. 

Fig. 128. 




Irrigating-apparatus. (Erichsen.) 

Antiseptic irrigation employed in this manner will be 
found a most useful method of treating lacerated and con- 
tused wounds of the extremities in which the vitality of 
the tissues is much impaired ; and in such cases warm 
water should be preferred to cool water, the temperature 
being from 100° to 110°. 

Under the use of warm irrigation it is surprising to see 
how tissues apparently devitalized regain their vitality; 
the absence of tension from the non-introduction of sutures 
and firm dressings, and the warmth and moisture kept con- 
stantly in contact with the wound by this method of irri- 
gation, are the important factors in the attainment of this 
favorable result. 



174 



MINOR SURGERY. 



Mediate Irrigation. In this method of irrigation cold 
or warmth is applied to the surface by means of cold or 
warm water passing through a rubber tube in contact with 
the part. A flexible tube of India-rubber half an inch in 
diameter, with thin walls, and sixteen or twenty feet in 
length, is applied to the limb like a spiral bandage, or is 
applied in a coil to the head, breast, or joints, and held in 
place by a few turns of a bandage; the end of the tube is 
attached to a reservoir filled with cold or warm water 



Fig. 129. 




Cold coil applied to arm. (Esmarch.) 



above the level of the patient's body, and the water is 
allowed to flow constantly through the tubing and escape 
into a receptacle arranged to receive it (Fig. 129). 

Cold-water Dressings. These dressings are applied by 
bringing the cold water either directly in contact with the 
part or by applying it by means of a rubber bag or blad- 
der. The temperature of the water may vary from cool 
water to that of ice-water. 

These dressings are employed in local inflammatory 



CO UNTER-IBBITATION. 175 

conditions; a favorite method for the employment of this 
dressing is by means of cold compresses, which are made 
of a few layers of surgical lint, dipped in water of the 
desired temperature and applied to the part; they are re- 
newed as soon as they become warm. When it is desir- 
able to have the compresses very cold, they may be laid 
upon a block of ice or in a basin with broken ice; to 
obtain the best results from their employment they should 
by renewed at very short intervals. 

A convenient method of applying cold without moisture 
is by the use of the ice-bag. This is either a rubber bag 
or bladder, which is filled with broken ice and applied to 
the part. In using an ice-bag it is better to cover the part 
first with a towel or a few layers of lint or muslin, which 
prevents the surface from becoming wet by absorbing the 
moisture which condenses upon the surface of the bag or 
bladder, and thus renders the dressing more comfortable 
to the patient. The ice-bag is often employed as an appli- 
cation to the head in inflammatory conditions of the brain 
or membranes; to the abdomen in cases of appendicitis, 
and is also used upon the surface of the body to control 
internal hemorrhage. 



COUNTER-IRRITATION. 

Counter-irritants are substances employed to excite ex- 
ternal irritation, and the extent of their action varies 
according to the material used and the duration of their 
application; superficial redness or complete destruction of 
the vitality of the parts to which they are applied may 
result. 

The use of counter irritants under favorable circum- 
stances is found to have a decided effect in modifying 
morbid processes, and they are widely employed as local 
revulsants in cases of congestion or inflammation, and in 
cases of collapse for their stimulating effect. 

Caution should be exercised in applying counter-irri- 
tants to patients who are comatose or under the influence 



176 MINOR SURGERY. 

of a narcotic, for here the sensations of a patient cannot 
be used as guide to their removal, and their too long- 
continued application when the vitality of the tissues is 
impaired may result in serious consequences. 

Rubefacients. These agents, by reason of their irri- 
tating properties when applied to the skin, produce intense 
redness and congestion. 

Hot Water. When it is desired to make a prompt im- 
pression upon the skin, the application of muslin or flannel 
cloths wrung out in hot water and renewed as rapidly as 
they become cool will soon produce a superficial redness of 
the integument. 

Spirits of Turpentine. This drug applied to the skin is 
a very active counter-irritant; it may be rubbed upon the 
surface of the skin until redness results. When used upon 
patients whose skin is very delicate its action may be modi- 
fied by mixing it with equal parts of olive oil before apply- 
ing it; this will be found useful in applying it as a rube- 
facient to the tender skins of young children. 

When redness of the skin has resulted from the appli- 
cation the skin should be wiped dry by means of a soft 
towel or absorbent cotton to remove any turpentine from 
the surface, which by its continued contact may cause 
vesication. 

Turpentine Stupe. This is prepared by sprinkling spirits 
of turpentine over flannel cloths which have been wrung 
out in hot water, or by dipping hot flannel in warm spirits 
of turpentine; prepared in either way the stupe should be 
squeezed as dry as possible to remove the excess of tur- 
pentine before being applied to the surface of the body. A 
turpentine stupe may cause vesication if allowed to remain 
for too long a time in contact with the skin; its application 
for from five to ten minutes will usually produce the de- 
sired effect; it should be removed after this time, and it 
can be reapplied if desired. 

If the patient complains of severe burning of the skin 
after the use of turpentine, the painful surface should be 
freely smeared with vaseline or lard, which will relieve 
the uncomfortable symptom. 






CO UNTER-IRR1TA TION. \ 77 

Chloroform. A few drops of chloroform applied to the 
surface of the body by means of a piece of lint, muslin, 
or flannel, and covered by oiled silk or rubber-tissue, will 
excite a rapid rubefacient effect. 

Mustard. Ground mustard or mustard flour prepared 
from either Sinapis alba or Sinapis nigra is one of the 
most commonly used substances to produce rubefacient 
action. It is generally employed in the form of the mus- 
tard plaster or sinapism, which is prepared by mixing equal 
parts of mustard flour with wheat flour or flaxseed meal, 
and adding to this enough warm water to make a thick 
paste; this is spread upon a piece of old muslin, and the 
surface of the paste should be covered with some thin 
material, such as gauze, to prevent the paste from adhering 
to the skin. In making a mustard plaster for application 
to the tender skin of a child, 1 part of mustard flour should 
be mixed with 3 parts of wheat flour or flaxseed meal. 

A mustard plaster or sinapism may be allowed to remain 
in contact with the skin for a period varying from fifteen 
to thirty minutes, the time being governed by the sensa- 
tions of the patient; if it is allowed to remain longer, it 
may cause vesication, which is to be avoided, as ulcers 
produced by mustard are very painful and extremely slow 
in healing. After removing a sinapism the irritated sur- 
face of the skin should be dressed with a piece of muslin 
or lint spread with vaseline, boric acid or oxide of zinc 
ointment. 

To excite a rapid revulsive action the mustard foot-bath 
is often employed; it is prepared by adding two or three 
tablespoonf uls of mustard flour to a bucket or foot-tub of 
water at a temperature of 100° to 110° ; in this the patient 
is allowed to soak his feet for a few minutes. 

Mustard Papers. Charta Sinapis, which can be obtained 
in the shops ready for use, are a convenient means of 
obtaining the rubefacient action of mustard. They are 
dipped in warm water, and as they are generally very 
strong, it is well to place a layer of muslin between the 
surface of the plaster and the skin before applying it to 
the surface. 

12 






178 MINOR SURGERY. 

Capsicum. This is also sometimes employed as a rube- 
facient, but it is generally employed in combination with 
spices, forming the well-known spice plaster ; this is pre- 
pared by taking equal parts of ground ginger, cloves, cin- 
namon, and allspice, and adding to them one-fourth part 
of Cayenne pepper; these are thoroughly mixed, enclosed 
in a flannel bag, and evenly distributed; a few stitches 
should be passed through the bag at different points, to 
prevent the powder from shifting its position; before ap- 
plying it, one side of the bag should be wet with warm 
whiskey or alcohol. Capsine plasters are also employed 
to obtain the rubefacient effect of Cayenne pepper. 

Aqua Ammonia. This may also be employed for its 
rubefacient action. A piece of lint saturated with the 
stronger water of ammonia, placed upon the skin and 
covered with waxed paper, and allowed to remain for one 
or two minutes, will produce a marked rubefacient effect. 

Paquelin's Cautery. By rapidly stroking the surface of 
the skin with the point or button of Paquelin's cautery 
at a black heat a marked counter-irritant action may be 
produced. 

Vesicants. Where it is desirable to make a more per- 
manent counter-irritant effect than that produced by rube- 
facients, substances are employed which by their action on 
the skin cause an effusion of serum, or of serum and 
lymph, beneath the cuticle, thus giving rise to vesicles or 
blisters; they are known as vesicants. 

The substance most commonly employed to produce 
vesication is Cantharis, or Spanish fly, and the prepara- 
tion commonly used is the Ceratum cantharidis. 

Fly Blister. This is prepared by spreading ceratum 
cautharidis upon adhesive plaster, leaving a margin one- 
half an inch in width uncovered, which will adhere to the 
skin and hold the blister in position. The time required 
for a fly blister to produce vesication is from four to six 
hours; it should then be removed and the surface should 
be covered with a flaxseed-meal poultice, or with a warm- 
water dressing. When the blister or vesicle is well devel- 
oped, it may be punctured at its most dependent part to 



CO TJNTER-IRRITATION. 1 79 

allow the serum to escape, and it should be dressed with 
vaselin or boric ointment. If for any reason it is desired 
to keep up continued irritation, after allowing the serum 
to escape, the cuticle should be cut away and the raw sur- 
face should be dressed with some stimulating material, 
such as the compound resin cerate. 

Cantharidal Collodion. This may be employed to pro- 
duce vesication; it is applied by painting several layers 
upon the skin with a brush over the part on which the 
blister is to be produced. It is a convenient preparation 
to use when the patient would disturb the ordinary blister, 
as in the case of a child or an insane patient, or where the 
surface is so irregular that the ordinary blister cannot be 
well applied. The after-treatment of blisters produced 
by cantharidal collodion is similar to that previously de- 
scribed. 

Caution should be observed rn using blisters upon the 
tender skins of children; if employed, they should be 
allowed to remain in contact with the skin for a short 
time only. They are contraindicated in patients in whom 
the vitality of the tissues is depressed by adynamic dis- 
eases, and in aged persons. 

Strangury, w T hich is shown by frequent and painful mic- 
turition, the urine often containing blood, sometimes occurs 
from the use of cantharidal preparations as blisters. This 
condition should be treated by the use of opium and bel- 
ladonna by suppository, demulcent drinks, and warm sitz- 
baths, and by leeches to the perineum if the symptoms are 
very severe. 

To avoid the development of strangury small blisters 
should be employed, and should not be allowed to remain 
too long in contact with the surface, and cantharidal prepa- 
rations should not be employed in cases where renal or 
vesical irritation has existed or is present. It is said that 
strangury may also be avoided by incorporating opium 
and camphor with the cantharidal cerate. 

Aqua Ammonia Fortior and Chloroform. These drugs 
may be employed to produce rapid vesication, a few drops 
being placed upon the surface of the body and covered by 



180 



MINOR SURGERY. 



Fig. 130. 



an inverted watch-glass for a few minutes, or lint satu- 
rated with aqua ammonia or chloroform may be placed 
upon the skin and covered with waxed paper or oiled silk. 
Either of these agents applied in this manner, and allowed 
to remain in contact with the skin for fifteen minutes, will 
produce marked vesication. The blisters resulting from 
these agents are painful, and they are only to be used 
where a rapid result is desired. 

Acupuncture. Counter-irritation is effected by this 
method by thrusting steel needles deeply into the subcu- 
taneous tissues. The needles employed should be of steel, 
from two to four inches in length, strong, 
highly polished, and sharp-pointed, and 
should have round metallic heads or be 
fixed in handles (Fig. 130). Before being 
used they should be immersed for a few 
minutes in boiling water or in a carbo- 
lized solution to sterilize them thoroughly. 
In performing the operation of acupunc- 
ture, localities containing important or- 
gans, large bloodvessels, the joints and 
viscera, should be avoided. When in- 
troduced the needles should be passed 
through the skin with a rotary motion, 
the skin being rendered tense between the 
thumb and fingers, and pushed into the 
deep-seated structures. They are allowed 
to remain in position for a few moments 
and are then withdrawn, the skin being 
Acupuncture needles, supported by the thumb and fingers. 

Acupuncture has been found of service 
in cases of deep-seated neuralgia, obstinate rheumatic 
affections, and sciatica. 

Actual Cautery. This method of counter-irritation is 
accomplished by bringing in contact with the skin some 
metallic substance brought to a high degree of tempera- 
ture. This constitutes one of the most powerful means of 
counter-irritation and revulsion; it is rapid in its action, 
and is not more painful than some of the slower methods. 



ACTUAL CAUTERY. 



181 



The cauteries generally employed are made of iron, and 
are fixed in handles of wood or other non-conducting 
material, and have their extremities fashioned in a variety 
of shapes (Fig. 131). The irons are heated by placing 
their extremities in an ordinary fire, or by holding them 
in the flame of a spirit-lamp until they are heated to the 
desired point, either a white or a dull-red heat. They are 
then applied to the surface of the skin at one point, or 
drawn over the skin in lines either parallel to or crossing 
one another. The intense burning which follows the use 
of the cautery may be allayed by placing upon the cautery- 
marks compresses wrung out in ice- water or saturated with 
equal parts of lime-water and sweet oil. 



Fig. 131. 




Cautery irons. 

Where the ordinary cautery irons are not at hand, a 
steel knitting-needle or iron poker heated in the flame of 
a spirit-lamp or in a fire may be employed with equally 
satisfactory results. Where the cautery iron is held in 
contact with the surface for some time to make a deep 
burn, the pain of its application may be allayed by placing 
a mixture of salt and cracked ice upon the spot to be cau- 
terized for a few minutes immediately before its application. 
The cautery iron should not be placed over the skin cover- 
ing salient parts of the skeleton or over important organs. 

The actual cautery, in addition to its use in producing 
counter-irritation and revulsion, is often employed to con- 
trol hemorrhage and to destroy morbid growths. 



182 



MINOR SURGERY. 



Paquelin's Thermo-cautery. A very convenient and 
efficient means of using the thermo-cautery is the appa- 
ratus of Paquelin, which utilizes the property of heated 
platinum -sponge to become incandescent when exposed to 
the action of the vapor of benzole or rhigolene (Fig. 132). 
The cautery is prepared for use by attaching the gum tube 
to the receiver containing benzole and heating the plati- 
num knife or button, which is also attached to the benzole 
receiver by a rubber tube, in the flame of the alcohol lamp 



Fig. 132. 




Paquelin's cautery. 



for a few moments, and then passing the vapor of benzole 
through the platinum -sponge, which is enclosed in the 
knife or button, by compressing the rubber bulb. The 
point may be brought to a high degree of white heat, or 
may be brought only to a dull-red heat. 

This form of cautery may be employed for the same 
purposes as that previously mentoned; its great advantage 
consists in the ease with which it can be prepared for use. 



BLOODLETTING. 183 

The knives heated to a dull-red heat will be found of 
great service in operating upon vascular tumors, where 
the use of an ordinary knife would be accompanied by 
profuse or even dangerous hemorrhage. Wounds made 
by the actual cautery are aseptic wounds, and when dusted 
with an antiseptic powder, generally heal promptly under 
the scab without suppuration. 

Seguin's Method of Counter-irritation. This consists in 
stroking the surface of the skin lightly and rapidly with 
the point of a Paquelin cautery; the lines of stroking may 
be made at right angles; the application is practically pain- 
less, but a very decided counter-irritant effect is produced. 
It is employed with advantage in neuralgic affections, and 
is of marked service in cases of neuralgic affections of the 
spine and joints, and in cases of neuritis of superficial 
nerves. 

BLOODLETTING. 

This procedure is often resorted to, to obtain both the 
local and the general effects following the withdrawal of 
blood from the circulation. Local depletion is accom- 
plished by means of some one of the following procedures: 
scarification, puncturation, cupping, and leeching, and gen- 
eral depletion is effected by means of venesection or by 
arteriotomy . 

Scarification. Scarification is performed by making 
small and not too deep incisions into an inflamed or con- 
gested part with a sharp-pointed bistoury; the incisions 
should be in parallel lines and should be made to corre- 
spond to the long axis of the part, and care should be 
taken in makiug them to avoid wounding superficial veins 
and nerves. Incisions thus made relieve tension by allow- 
ing blood and serum to escape from the engorged capil- 
laries of the infiltrated tissue of the part. Warm fomen- 
tations applied over the incisions will increase and keep 
up the flow of blood and serum. Scarification is employed 
with advantage in inflammatory conditions of the skin and 
subcutaneous cellular tissue and in acute inflammatory 



184 MINOR SURGERY. 

swelling or oedema of the mucous membrane; for instance, 
of the conjunctiva, and in acute inflammation of the ton- 
sils, tongue, and epiglottis it is an especially valuable pro- 
cedure. 

A modification of scarification known as deep incisions 
is practised in urinary infiltration to establish drainage 
and to relieve the tissues of the contained urine, and to 
prevent sloughing; in threatened gaugrene and phlegmon- 
ous erysipelas the same procedure is adopted to relieve 
tension by permitting of the escape of blood and serum, 
and its employment is often followed by most satisfactory 
results. 

Puncturation. This procedure consists in making punc- 
tures into inflamed tissues with the point of a sharp- 
pointed bistoury, which should not extend deeper than 
the subcutaneous tissue; it is an operation similar in char- 
acter to that just described, its object being to relieve ten- 
sion and bring about depletion. It is employed in cases 
similar to those in which scarification is indicated, and is 
resorted to in cases of diffuse areolar inflammation or 
erysipelas. 

Cupping'. Cupping is a convenient method of employ- 
ing local depletion by inviting the blood from the deeper 
parts to the surface of the body. Cupping is accomplished 
by the use of dry or wet cups. When the former are used, 
no blood is abstracted and the derivative action only is 
obtained; when wet cups are employed there is an actual 
abstraction of blood or local depletion as well as the deriv- 
ative action. 

Dry Cupping. Dry cups as ordinarily applied consist of 
small cup-shaped glasses, which have a valve and stop- 
cock at their summit; these are placed upon the skin and 
an air-pump is attached, and as the air is exhausted in 
the cup the congested integument is seen to bulge into the 
cavity of the cup. When the exhaustion is complete the 
stop-cock is turned and the air-pump is removed, the cup 
being allowed to remain in position for a few minutes, and 
is then removed by turning the stop-cock and allowing the 
air again to enter the cup. This procedure is repeated 



BLOODLETTING. 



185 



Fig. 133. 




until a sufficient number of cups have been applied. (Fig. 
133). 

In cases of emergency, when the ordinary cupping- 
glasses and air-pump cannot be obtained, a very satisfac- 
tory substitute may be obtained by taking a wineglass and 
burning in it a little roll of paper, or a small 
piece of lint or paper wet with alcohol, and 
before the flame is extinguished rapidly in- 
verting it upon the skin, or the air may be 
exhausted by the introduction, for a moment 
or two, of the flame of a spirit-lamp into the 
cup. Applied in this manner cups will draw 
as well as when the more complicated appa- 
ratus is used, and when they are to be removed 
it is only necessary to press the finger on the 
skin close to'the edge of the cup until air enters 
it, when it will fall off. Although dry cups 
do not remove blood directly, there is often 
an escape of blood from the capillaries into 
the skin and cellular tissue, as is evidenced by 
the ecchymosis which frequently remains at 
the seat of the cup-marks for some days. 

Wet Cupping. When the abstraction of 
blood as well as the derivative action is de- and air-pump. 
sired wet cups are resorted to, and here it is 
necessary to have a scarificator as well as the cups and air- 
pump (Fig. 134). 

Before applying wet cups the skin should be washed 
carefully with bichloride or carbolic solution, and the scari- 
ficator should also be dipped in a carbolic solution. A cup 
is first applied to produce superficial congestion of the skin; 
this is removed and the scarificator is applied, and the skin 
is cut by springing the blades. The cups are immedi- 
ately reapplied and exhausted, and they are kept in place 
as long as blood continues to flow. When the vacuum is 
exhausted and blood ceases to flow, they should be re- 
moved and emptied, and can be reapplied if it is desirable 
to remove more blood. A sharp-pointed bistoury which 
has been sterilized may be employed to make a few incis- 





186 MINOR SURGERY. 

ions into the skin instead of the scarificator, and the 
improvised cups may be employed if the ordinary cup- 
ping-apparatus cannot be obtained. 

After the removal of wet cups the skin should be 

washed carefully with a bichloride or carbolic solution, 

and an antiseptic dressing should 

fig. 134. k e placed over the wounds and held 

in place by a roller bandage. 

Leeching. In the abstraction of 
blood by leeching two varieties of 
leeches are used — the American 
leech, which draws about a tea- 
spoonful of blood, and the Swedish 
leech, which draws three or four 
teaspoonfuls. 

Before applying leeches the skin 
scarificator. should be carefully washed, and 

the leech should be placed upon the 
part from which the blood is to be drawn, and confined to 
this place by inverting a tumbler or glass jar over it; if it 
does not bite or take hold, a little milk or blood should be 
smeared upon the surface, which will generally secure the 
desired result. As soon as the leech has ceased to draw 
blood it is apt to let go its hold and fall off; if, however, 
it is desired to remove leeches, they may be made to let go 
their hold by sprinkling them with a little salt. After the 
removal of leeches bleeding from the bites may be encour- 
aged, if desirable, by the application of warm fomenta- 
tions. Leech-bites should be washed with a bichloride or 
carbolic solution, and a compress of bichloride or iodoform 
gauze placed over them and secured by a bandage. 

It sometimes happens that free bleeding continues from 
the leech-bite after the removal of the leeches; in this 
event, if a compress does not control the hemorrhage, the 
bleeding point should be touched with a stick of nitrate 
of silver or with the point of a steel knitting-needle heated 
to a dull-red heat, and if this fails to control the bleeding 
a delicate harelip pin should be passed through the skin 
under the bite and a twisted suture thrown around this; 



VENESECTION. 



187 



Fig. 135. 



V Si 



the wound should then be washed and dressed as previ- 
ously described. 

In applying leeches in or near mucous cavities care 
should be taken to see that they do not escape into the 
cavities and pass out of reach. Leeches should not be 
employed directly over inflamed tissue, but should be ap- 
plied to parts surrounding it; they should not be allowed 
to take hold directly over a superficial artery, vein, or 
nerve, and should never be applied to a part where there 
is delicate skin and a large amount of loose cellular tissue, 
as in the eyelid or scrotum, as unsightly 
ecchymoses will result, which will persist 
for some time. Leeches should not be used 
a second time. 

The Mechanical Leech. The mechanical 
leech is an apparatus which has been con- 
structed to take the place of the leech ; it 
consists of a scarificator, cup, and exhaust- 
ing syringe or air-pump. (Fig. 135.) In 
using this apparatus, after the scarificator 
has been used the piston of the exhausting- 
instrument should be drawn out slowly, 
which secures a better flow of blood than if 
a sudden vacuum is made. 

The mechanical leech may be employed 
when the natural leech cannot be obtained, 
but possesses no advantage over the latter, 
and is apt to get out of order if not in 
constant use. 

Venesection. Venesection, as its name 
implies, consists in the division of a vein, Mechanical 
and it is the ordinary operation by which 
general depletion or bleeding is accomplished. Vene- 
section at the bend of the elbow is the operation which 
is now usually resorted to for general blood letting ; the 
vein selected is the median cephalic, which is further 
from the line of the brachial artery than the median 
basilic vein. (Fig. 136.) 

To perform venesection the surgeon requires a bistoury 



188 MINOR SURGERY. 

or lancet — the spring lancet was formerly much used, but 
it is not employed at the present time — several bandages, 
a small antiseptic dressing, and a basin to receive the blood. 

Fig. 136. 




Venesection. (Heath.) 

The patient's arm should be carefully cleansed, washed 
over with a bichloride solution, and a few turns of a 
roller bandage placed around the middle of the arm, 
being applied tightly enough to obstruct the venous circu- 
lation and make the veins below become prominent, but 
not tight enough to obstruct the arterial circulation. The 
patient at the same time should be instructed to grasp a 
stick or a roller bandage and work his fingers upon it. 
The surgeon should next assure himself that there is no 
abnormal artery beneath the skin, and having selected the 
vein, the median cephalic by preference, he then steadies 
the vein with his thumb and passes the point of the bis- 
toury or lancet beneath it and cuts quickly outward, 
making a free skin opening. The blood usually escapes 
freely, and the amount withdrawn is regulated by the con- 
dition of the pulse and the appearance of the patient. For 
this reason it is better to have the patient sitting up or 
semi-reclining when venesection is performed, as the sur- 
geon can judge better as to the constitutional effects of the 
loss of blood while the patient is in this position. 

AYhen a sufficient quantity of blood has been removed, 
the thumb is placed over the wounded vein and the ban- 
dage is removed from the arm above. The wound is next 
washed with a bichloride solution, and a compress of anti- 



TRANSFUSION OF BLOOD. 189 

septic gauze is applied over the wound and held in posi- 
tion by a bandage which should be so applied as to envelop 
the limb from the fingers to the axilla. The dressing need 
not be distured for five or six days, at which time the 
wound is usually found to be healed. 

Wounds of the brachial artery have occurred in opening 
the veins at the bend of the elbow, but if care is taken, 
this accident should not take place. 

Venesection may be practised on the external jugular 
vein when, from excess of fat or in the case of children, 
the veins at the bend of the elbow cannot be easily found. 
The vein is rendered prominent by placing the thumb or 
a pad over the vein at the outer edge of the sterno-cleido- 
mastoid muscle just above the clavicle. The vein is next 
opened over this muscle by an incision parallel to its fibres. 
After a sufficient quantity of blood has escaped, the wound 
is washed with an antiseptic solution and closed by a com- 
press of antiseptic gauze held in position by a bandage 
carried around the neck. 

The internal saphenous vein is also sometimes selected for 
venesection, and here care should be taken not to wound 
the accompanying nerve which lies directly behind the vein. 

Arteriotomy. This operation is now scarcely ever per- 
formed, but if done the vessel generally selected is the 
anterior branch of the temporal artery. The position of 
the vessel is fixed by the finger and thumb, and it is 
opened by a transverse incision with a bistoury. After a 
sufficient quantity of blood has escaped the wound is in- 
spected, and if the vessel is not completely divided, its 
division is completed and the ends of the vessel should be 
secured with ligatures, and the wound irrigated with an 
antiseptic solution and closed with sutures. A gauze 
compress should next be applied and held in position by 
a firmly-applied bandage. 

TRANSFUSION OF BLOOD. 

This operation may be employed to introduce a certain 
quantity of blood into the circulaion of a patient who has 



190 MINOR SURGERY. 

suffered from profuse hemorrhage; it is rarely employed at 
the present time, being almost entirely superseded by the 
transfusion or infusion of saline solution. There are two 
methods by which transfusion may be effected : the direct, 
by which the blood is conveyed directly and without ex- 
posure to the air from the bloodvessel of one person to that 
of another, and the indirect, in which the blood is first 
drawn from one person and is then injected into the veins 
of another, being first deprived of its fibrin before being 
injected. 

Direct Transfusion of Blood. This is best accom- 
plished by using Aveling's apparatus, which consists of a 
rubber tube, about eighteen inches in length, with a small 
bulb in the centre, having metallic extremities provided 
with stop -cocks, and two bevel-pointed metallic canulse to 
be used to connect the tube with the bloodvessels. In 
performing the operation of direct transfusion the bulb 
and tube are first placed in a shallow basin containing 
warm normal saline solution (0.7 per cent.), and the bulb 
and tube are filled with this solution to displace any air 
which they may contain. The person supplying the blood 
places his arm near the arm of the patient, and the oper- 
ator exposes a prominent vein on the patient's arm at the 
bend of the elbow, opens it, and inserts into it one of the 
canulse filled with saline solution, with the point directed 
toward the body, and at the same time an assistant should 
introduce the other canula into a vein at the bend of the 
elbow of the party who supplies the blood. 

The canulae are held in position by assistants, and the 
tube is quickly connected with them, the stop-cocks being 
closed before it is taken out of the saline solution, to pre- 
vent the entrance of air; then upon opening the stop-cocks 
a direct communication is established between the circula- 
tion of the patient and that of the person who supplies the 
blood. (Fig. 137.) The introduction of the contents of 
the bulb into the vein of the patient is effected by the 
operator slowly compressing the bulb with one hand, while 
he keeps the tube closed on the side of the donor with 
the finger and thumb of the other hand. By relaxing the 






TRANSFUSION OF BLOOD. 



191 



pressure on the tube on the donor's side of the bulb and 
closing it on the patient's side, blood will flow from the 
donor's vein into the bulb as it slowly expands, and when 
filled the communication with the patient's circulation is 
again made, aud the manipulation is repeated until a suffi- 
cient quantity of blood has been introduced, as indicated 
by the condition of the patient's pulse. 




Apparatus for the direct transfusion of blood. 



The quantity of blood introduced can be calculated by 
remembering that at each emptying of the bulb two 
drachms of fluid are introduced into the circulation. 
When a sufficient quantity has been introduced the canulse 
are removed and the wounds are dressed as ordinary vene- 
section wounds. 

Indirect Transfusion of Blood. Indirect transfusion 
of blood, which is now rarely employed, is accomplished 
by withdrawing from a vein of the donor by venesection 
about ten ounces of blood, which is received in a sterilized 
glass or porcelain vessel, which is placed in water at a 
temperature of 110°. The blood thus kept warm is next 
defibrinated by whipping it with a bundle of broom straws 



192 MINOR SURGERY. 

or a wire brush, and after being filtered through a fine 
linen cloth or wire strainer, it is injected by means of an 
ordinary syringe attached to a canula which has previously 
been inserted into a vein of the patient; care should be taken 
that no air is introduced with the blood. When a sufficient 
quantity of blood has been introduced the canula is re- 
moved and the wound is dressed in the usual manner. 
The success of this operation largely depends upon the 
expedition with which it is performed; to prevent the 
coagulation of the blood not more than two minutes should 
be allowed to intervene between the reception of the blood 
in the syringe and its introduction into the patient's vein. 

Arterial Transfusion. This procedure, which consists 
in injecting defibrinated venous blood into an artery, is 
occasionally practised. An artery, usually the radial at 
the wrist or the posterior tibial behind the inner malleolus, 
is exposed and secured by a ligature; it is then opened on 
the distal side of the ligature and the point of a canula or 
the nozzle of a syringe is introduced, directed toward the 
distal extremity of the limb, and blood, which has been 
previously defibrinated, is slowly injected. When a suffi- 
cient quantity has been introduced the canula is removed, 
and the division of the artery is completed and its extremi- 
ties are secured by ligatures, and the wound is closed and 
dressed. 

Auto transfusion. This procedure is recommended in 
cases of excessive hemorrhage to support a moribund 
patient until other means of resuscitation can be adopted. 
It consists in the application of rubber bandages or of 
muslin bandages to the extremities for the purpose of 
forcing the blood toward the vascular and nervous centres. 



INTRAVENOUS INJECTION OF SALINE SOLUTION. 

It has been proved by experiments and by clinical ex- 
perience that human blood is not more efficacious in sup- 
plying volume to and restoring a rapidly failing circulation 
than normal salt solution, and as the latter can be obtained 



INJECTION OF SALINE SOLUTION. 193 

with much more ease than blood, its use has largely super- 
seded the former. The saline solution which is found most 
satisfactory to employ for this purpose is known as normal 
saline solution (0.7 per cent.). It is prepared by adding 
sodium chloride, 5jss, sodium bicarbonate, grs. xv, to 
distilled water, Oij. In emergencies a solution prepared 
by adding a drachm of common salt to a pint of water, 
which has been sterilized by boiling, will be equally satis- 
factory. 

The solution should be prepared with water which has 
been boiled to sterilize it, and should be of a temperature 
of about 100° when used. 

A vein of the patient, at the elbow, should be exposed 
and should have placed under it, about one-half inch apart, 
two catgut ligatures; the distal ligature is then tied and an 
opening is made into the vein between the ligatures; a 

Fig. 138. 




Funnel and tube for intravenous injection. 

canula is next inserted into the opening in the vein, and 
is secured in position by tying the proximal ligature. The 
canula is first filled with the saline solution, and is then 
connected with a funnel by means of a rubber tube (Fig. 

13 



1 94 MINOR S tfR GER Y. 

138), which is filled with saline solution to displace the air, 
and upon raising the funnel above the part the solution 
enters the vein; care should be taken to see that the funnel 
is kept well supplied with the solution until a sufficient 
quantity has been introduced. The quantity introduced 
is regulated by the condition of the patient's pulse. 

Saline solution may also be introduced into a vein by 
means of a syringe when the apparatus described cannot 
be obtained. 

Infusion of Saline Solution. The introduction of saline 
solution into the cellular tissue has been followed by results 
equally as satisfactory as those obtained by intravenous 
injection, and this procedure is now very frequently em- 
ployed. 

The saline solution is conveyed into the cellular tissue 
through a large hypodermic needle, which should be steril- 
ized by boiling, and is then introduced into the connective 
tissue, being previously connected by a rubber tube with 
a reservoir containing warm sterilized salt solution. The 
usual situations for the introduction of the solution are the 
external portions of the thighs and the anterior and lateral 
portions of the abdominal walls. As much as two or 
three pints of the solution are often introduced in this 
manner, with very satisfactory results. Infusion of saline 
solution may be used with most satisfactory results in cases 
who have suffered from profuse hemorrhage, and has also 
proved of great service in cases of shock. 



ARTIFICIAL RESPIRATION. 

This procedure is resorted to in cases of threatened death 
from apnoea consequent upon drowning, profound anesthe- 
tization, electric shock or the inhalation of irrespirable 
gases, or when from any cause there is interference with 
the function of breathing. Before resorting to artificial 
respiration care should be taken to see that nothing is 
present in the mouth or air-passages which will obstruct 
the entrance of air into the lungs, such as mucus, foreign 






ARTIFICIAL RESPIRATION. 195 

bodies or liquids, and also that all tight clothing interfer- 
ing with the free expansion of the chest- walls is removed 
from the chest. 

In cases where the apnoea is due to the presence of a 
foreign body in the larynx or trachea it is evident that no 
efforts at respiration can be successful until the air-pas- 
sages are freed from the occluding body; and if it cannot 
be removed through the mouth, tracheotomy should be 
performed before artificial respiration is attempted; the 
tracheal wound should be held open by retractors, which 
in a case of emergency can be made from bent hairpins, or 
by a dressing forceps or a tracheotomy-tube, if one be at 
hand. 

When artificial respiration is resorted to the operator 
should persevere with it for some time, even when no ap- 
parent spontaneous respiratory movements are excited; 
for resuscitation has been accomplished in seemingly hope- 
less cases by patient perseverance with the manipulations. 
When the first natural respiratory movement is detected 
the operator should not cease making artificial respiration, 
but should continue these movements in such a way as to 
coincide with the spontaneous inspiratory and expiratory 
movements until the breathing has assumed its regular 
character. 

The temperature of the body should also be restored by 
friction to the surface of the body by the hands or by 
rough towels and hot-water bottles, and warm coverings 
should be applied for the same object. 

Mouth to mouth Inflation. This method of artificial 
respiration has been resorted to in cases of great emer- 
gency, especially in very young children. The operator 
draws the tongue forward, closes the nostrils, and applies 
his mouth directly to the mouth of the patient, and by a 
deep expiratory effort endeavors to force air into the chest; 
when this is accomplished the air can be expelled from the 
lungs by pressure upon the walls of the chest, and the 
procedure should be repeated about sixteen times in a 
minute. The same object may be accomplished by pass- 
ing a flexible catheter into the trachea through the mouth, 



196 



MINOR SURGERY. 



and the lungs can be inflated by the operator blowing into 
the catheter. 

Direct Method of Artificial Respiration (Howard's). 
This method of artificial respiration is at the present time 
considered the most efficacious, and is the one adopted by 
the United States Life-saving Service, and although the 
rules given are for the resuscitation of cases of apparent 
drowning, the same procedures may be adopted in cases of 
apnoea arising from other causes. 

The rules laid down by Dr. Howard are as follows : 
Rule I. — " To expel water from the stomach and lungs 
strip the patient to the waist, and if the jaws are clenched 
separate them and keep them apart by placing between the 
teeth a cork or a small piece of wood. Place the patient 
face downward, the pit of the stomach being raised above 
the level of the mouth by a large roll of clothing placed 
beneath it. (Fig. 139.) Throw your weight forcibly two 



Fig. 1 




First manipulation in Howard's method. 



or three times upon the patient's back over the roll of 
clothing so as to press all fluids in the stomach out of the 
mouth." 

The first rule applies only to cases of drowning, and in 
using Howard's method in apnoea from other causes it is 
to be omitted. 



ARTIFICIAL RESPIRATION. 197 

Rule II. — " To perform artificial respiration, quickly 
turn the patient upon his back, placing the roll of clothing 
beneath it so as to make the breast-bone the highest point 
of the body. Kneel beside or astride of the patient's hips. 
Grasp the front part of the chest on either side of the pit 
of the stomach, resting the fingers along the spaces be- 
tween the short ribs. Brace your elbows against your 
sides, and steadily grasping and pressing forward and 
upward throw your whole weight upon the chest, gradu- 

Fig. 140. 




Direct method of artificial respiration. 

ally increasing the pressure while you count one — two — 
three. Then suddenly let go with a final push which 
springs you back to your first position. (Fig. 140.) Rest 
erect upon your knees while you count one — two ; then 
make pressure again as before, repeating the entire motions 
at first about four or five times a minute, gradually increas- 
ing them to about ten or twelve times. Use the same regu- 
larity as in blowing bellows and as seen in the natural 
breathing which you are imitating. If another person is 
present, let him with one hand, by means of a dry piece of 
linen, hold the tip of the tongue out of one corner of the 
mouth, and with the other hand grasp both wrists and pin 
them to the ground above the patient's head." This 



198 



MINOR SURGERY. 



method may be employed in cases of still-birth, or in 
young children, the operator holding the body of the child 
in his left hand and compressing it with the right hand. 

Silvester's Method of Artificial Respiration. In 
employing this method of artificial respiration the patient 
should be placed on his back upon a firm flat surface; a 
cushion of clothing is placed under the shoulders, and the 
head should be dropped lower than the body by tilting the 
surface on which he is laid. The mouth being cleared of 
mucus or foreign substances, the tongue is drawn forward 

Fig. 141. 




Silvester's method— Inspiration. (Esmarch.) 

and secured to the chin by a piece of tape tied around it 
and the lower jaw, or may be pulled out of the mouth 
and held by an assistant. The operator, standing at the 
patient's head, grasps the arms at the elbows and carries 
them first outward and then upward until the hands are 
brought together above the head; this represents inspira- 
tion (Fig. 141); they should be kept in this position for 
two seconds, after which time they are brought slowly 
back to the sides of the thorax and pressed against it for 
two seconds; this represents expiration (Fig. 142.) These 



ARTIFICIAL RESPIRATION. 199 

movements are repeated fifteen times in a minute until the 
breathing is restored, or until it is evident that the case is 
a hopeless one. 

Fig. 142. 



Silvester's method— Expiration. (Esmarch.) 

Marshall Hall's Method of Artificial Respiration. 

In this method the mouth should first be freed from 
mucus or foreign bodies, and the patient is turned upon 
his face with one wrist under his forehead, and a roll of 
clothing is placed beneath his chest. By turning the body 
briskly on the side and a little beyond, and then on the 
face, alternately, respiration is imitated. As the body is 
brought in the prone position compression is to be made 
upon the posterior aspect of the chest. These manipula- 
tions should be made fifteen times in a minute. 

Laborde's Method of Artificial Respiration. Laborde 
has shown that systematic and rhythmic traction upon the 
tongue is a powerful means of restoring the respiratory 
reflex, and consequently the function of respiration. The 
procedure is accomplished as follows : The body of the 
tongue is seized between the thumb and fingers, and trac- 
tion is made upon it with alternate relaxation, fifteen or 



200 MINOR SURGERY. 

twenty times a minute, imitating the function of respira- 
tion, taking care to draw well on the tongue. When a 
certain amount of resistance is felt it is a sign that the 
respiratory function is being restored. Noisy respiration 
first occurs, termed by Laborde hoquet inspirateur (inspi- 
ratory hiccough). Tongue forceps or dressing or haemo- 
static forceps may be used in place of the fingers to grasp 
the tongue. It is important to persist in the manipulations 
for half an hour to an hour, unless the case is absolutely 
hopeless. This procedure, which cannot be employed with 
advantage when there is fixation of the tongue from inflam- 
mation or malignant disease, has been employed with suc- 
cess in cases of drowning, toxic asphyxia, asphyxia during 
anaesthesia, and arrest of respiration from electric shock. 

Forced Respiration. By this method of artificial respi- 
ration air is forcibly passed into the lungs. This procedure 
is strongly advocated by Fell, who has devised an appa- 
ratus by which it may be satisfactorily accomplished. 
Prof. H. C. Wood has also made use of forced respiration 
in the resuscitation of animals with an apparatus some- 
what similar to that devised by Fell with good results. 
Wood's apparatus consists of a pair of bellows, a few feet 
of rubber tubing and a face mask of rubber, and one or 
two intubation-tubes; the mask or intubation-tube is 
attached to one end of the rubber tube and the bellows to 
the other end of the tube. The mask is applied over the 
mouth, or, if this is not used, the intubation-tube is intro- 
duced into the larynx, and air is forced into the lungs by 
working the bellows. He also advises that in the tubing 
a double metal tube be introduced, with the openings so 
placed that their size can be so regulated by turning the 
outer tube that the operator can allow any excess of air 
thrown by the bellows to escape. 

The apparatus of Fell, which he has used in a number 
of cases with good results, consists of a mouth-mask or 
tracheotomy-tube, and a tube connected with the air-con- 
trol valve, which is attached to an air-warming apparatus, 
which in turn is connected with a bellows by another tube. 
(Fig. 143.) By means of this apparatus air is forced into 



ASPIRATION. 



201 



the lungs, and allowed to escape, when the lungs have 
been expanded, by the elasticity of the lung tissue and 
the chest walls. 

Forced respiration has proved of value in cases of nar- 
cotic poisoning and other accidents in which death is pro- 
duced by paralysis of the respiratory centres. 

Fig. 143. 




Fell's apparatus for forced respiration. 

Aspiration. This procedure is adopted to remove fluid 
from a closed cavity without the admission of air, and the 
instrument which is employed to accomplish this object is 
known as an aspirator. The form of aspirator most gen- 
erally employed is that of Potain. 

Potain's aspirator consists of a glass bottle, into the 
stopper of which is introduced a metallic tube, which is 
connected with two rubber tubes, one of which is connected 
with an exhausting-pump, and the other with a delicate 
canula carrying a fine trocar; the apparatus is provided 
with stop-cocks to preveut the admission of air. (Fig. 
144.) In using this aspirator the air is exhausted from 
the bottle by using the air-pump; the canula enclosing the 
trocar is next pushed through the tissues into the cavity 
containing the fluid to be removed; the trocar is then 
removed, and upon opening the stop-cock the fluid is 



202 



MINOR SURGERY. 



forced out of the cavity by atmospheric pressure and 
passes into the bottle or receiver. If the fluid contains 
masses of lymph or clots which block the canula, inter- 
rupting the flow of fluid, a stylet may be passed through 
the canula to free it from the obstruction. 



Fig. 144. 




Potain's aspirator. 



To diminish the pain produced in introducing the trocar 
and canula, the skin at the point to be punctured may be 
rendered less sensitive by holding in contact with it for a 
few minutes a piece of ice wrapped in a towel, or a towel 
containing broken ice and salt. Care should also be taken 
to see that the trocar and canula have been perfectly ster- 
ilized; to accomplish this they should be carefully washed 
and placed in boiling water or a 5 per cent, carbolic solu- 
tion before being used. In introducing the trocar and 
canula the operator should be careful to avoid injuring 
any important veins, arteries, or nerves. 

After removing the canula the small puncture should 
be dressed with a compress of antiseptic or iodoform gauze 
held in place by a bandage or adhesive straps. 

The aspirator is frequently employed in cases of hydro- 



THE STOMACH-TUBE. 203 

thorax, empyema, and ascites, to evacuate the contents of 
cold abscesses in diseases of the hip and spine, and to re- 
move the contents of a distended bladder until a more 
radical operation can be performed. It is also a valuable 
instrument for diagnostic purposes, being frequently used 
to ascertain the character of the contents of deep-seated 
tumors containing fluid. 

The Stomach-tube. This consists of a partially flex- 
ible tube about tweuty-eight inches in length and three- 
eighths of an inch in diameter, which is introduced while 
the patient is in the sitting posture, the head being thrown 
backward so as to bring the mouth and gullet as nearly as 
possible in the same line. The tube being warmed and 
oiled, the surgeon standing in front of the patient passes 
it directly back to the pharynx, at the same time intro- 
ducing the index finger of the left hand to guide its point 
over the epiglottis; it is then passed gently downward into 
the stomach. If any obstruction is met with in its pas- 
sage, it should be withdrawn a little way and then pushed 
gently downward; all manipulations should be made with- 
out much force, to prevent perforation of the wall of the 
oesophagus. 

Fig. 145. 



The introduction of the stomach-tube may be required 
for the evacuation of poisons from the stomach, or to wash 
out the cavity of this viscus. It may also be used to intro- 
duce liquid nourishment into the stomachs of patients who 
are unable or unwilling to swallow food. In introducing 
liquid nourishment a syringe or funnel is fitted to the 
exposed end of the tube which has been passed into the 
stomach; the syringe or funnel having been filled with 
milk or beef- tea or broth, the contents are injected gently 
or allowed to run into the stomach. 

In cases of poisoning, where it is desirable to withdraw 
the contents of the stomach and to wash out the organ, a 



204 



MINOR SURGERY. 



stomach-tube and syringe may be employed; several 
syringefuls of warm water are first thrown into the stom- 
ach and then withdrawn by suction, but in such cases the 
use of the stomach-pump will be found more satisfactory. 

Lavage. In the recently introduced method of treating 
disorders of the stomach and intestines by washing them 
out, the introduction of a flexible rubber stomach-tube is 
required; the tube here employed is from twenty-four to 
thirty inches in length (Fig. 145), and the fluid is intro- 
duced by means of a fuunel attached to its free extrem- 
ty, or it may be attached to a stomach-pump. 

The Stomach-pump. This consists of a brass syringe, 
the nozzle of which is connected with two tubes, one at 
the end, the other at the side. The passage through the 
nozzle is regulated by a valve controlled by a lever. The 
nozzle of the pump is attached to a stomach-tube, and the 

Fig. 146. 




Stomach-pump. 



end of the lateral tube is placed in a pan of warm water. 
By raising the piston and opening the valve, water may 
be drawn from the basin, and b^ closing the valve and 
depressing the piston it is passed through the stomach- 
tube into the stomach; when a sufficient quantity has been 
injected in this manner, by reversing the action of the 
valve the fluid is drawn out of the stomach and dis- 



THE RECTAL TUBE. 205 

charged through the lateral tube into a basin (Fig. 146). 
This manipulation is continued until the water returns 
clear and the stomach has been completely washed out. 

(Esophageal Bougie. This instrument — which may be 
passed through the oesophagus into the stomach for the 
purpose of diagnosis, or for the purpose of dilating stric- 
tures of the oesophagus — is passed in exactly the same 
manner as the stomach-tube, and, as in the case of the 
latter instrument, it should be introduced without the use 
of much force, as perforations of the oesophagus have fol- 
lowed the forcible introduction of such instruments. 

The Rectal Tube. The introduction of the rectal tube 
is best accomplished by placing the patient upon his left 
side, and the surgeon should introduce his index-finger 
well oiled into the rectum and guide the tube upon this 
through the anus, when by gentle pressure it is gradually 
passed into the rectum; if a stricture exists in the rectum 
within reach of the finger, the latter should be used to 
guide the tube through the opening in this; if the tube 
becomes caught in a transverse fold of the mucous mem- 
brane, and becomes doubled upon itself, it should be with- 
drawn and a fresh attempt should be made to pass it; in 
passing a rectal tube all manipulations should be made 
with extreme gentleness, as it has been shown that its 
passage is not without danger, perforations of the intestine 
having followed its use in some cases. In cases of stric- 
ture of the rectum high up the operator has to depend 
upon the sense of resistance experienced in passing the 
tube, and in such cases the manipulations should be most 
carefully made. When the rectal tube is employed to 
introduce fluids into the large intestine the fluids may be 
introduced by means of a syringe, or by pouring them 
into a funnel attached to the free end of the tube, or by 
attaching the tube to a fountain syringe, thus allowing the 
liquid to pass slowly into the intestine. 

The rectal tube is often employed with good results in 
relieving the intestine of excessive flatus, and in intro- 
ducing water or oil into the intestine in cases of intestinal 
obstruction, and in those cases where the obstruction results 



206 MINOR SURGERY. 

from intussusception or fecal accumulations its use will 
often prove satisfactory. 

Rectal Bougies. These instruments are made of India 
rubber or the same material as the English flexible cathe- 
ter, and are of various sizes. They should first be oiled, 
and carefully introduced in the same manner as the rectal 
tube. They are generally employed in cases of stricture of 
the rectum, and they should be introduced with great care 
to avoid perforating the wall of the rectum; this accident 
has occurred in the hands of skilful surgeons. A very 
satisfactory substitute for a rectal bougie is a tallow can- 
dle, one end of which is melted or rubbed down to a con- 
ical shape. 

Enemata. These may be administered by means of the 
ordinary syringe, or by means of a gravity or fountain 
syringe; the precautions which should be observed are to 
introduce the nozzle of the syringe gently and in the right 
direction, as perforation of the lower portion of the rectum 
has taken place from the careless and forcible introduction 
of the nozzle of the enema-syringe; the fluid should also 
be injected slowly, as by so doing there is less resistance 
and less tendency for the patient to pass the fluid before 
the desired quantity has been introduced. 

The enema most commonly employed to empty the lower 
bowel is made by adding a tablespoonful of sweet oil and 
two teaspoonf uls of spirits of turpentine to one or two pints 
of warm water in which a little castile soap has been dis- 
solved; warm water and sweet oil are also frequently used 
for the same purpose. 

Glycerin Enema. One or two teaspoonf uls of glycerin 
injected into the rectum, or a suppository made of glycerin, 
will often be found an efficient substitute for the larger 
enemata of water. 

Nutritious Enema. When it is found necessary to resort 
to feeding by the rectum, the substances employed should 
be injected into the rectum by means of a syringe, and 
care should be taken to see that the quantity is not too 
large, and that it is of such a nature as not to cause any 
irritation of the walls of the rectum, or it will not be re- 






VACCINATION. 207 

tained ; two to four ounces in the case of an adult is gen- 
erally a sufficient quantity to inject at one time. 

Peptonized milk or beef juice, or the yolk of an egg 
beaten up with milk, is often employed, and any unirri- 
tating drugs may be mixed with the enema and adminis- 
tered at the same time. 

Vaccination. This is a minor surgical procedure which 
every physician is called upon to perform. The surface 
may be prepared for the reception of the lymph by abrad- 
ing the skin at one or two points with a dull lancet, or 
by making several superficial incisions with a knife, or 
by scratching the surface of the skin with the ivory point 
charged with lymph, in lines with crossing lines, cross- 
scratch, until a little serum exudes. It is not advisable 
to draw blood, which washes away the lymph, and for 
this reason we prefer the abraded surface made by the dull 
knife or the ivory point. 

The lymph used may be the humanized or the bovine. 

Bovine lymph or virus, which is now most generally em- 
ployed, is taken from the vaccine vesicles upon the udders 
and teats of heifers. The lymph may be mixed with ster- 
ilized glycerin and placed in fine glass tubes which are 
sealed, or ivory points or quills are dipped in the lymph 
and allowed to dry, and in using them they are dipped in 
water for a moment, to moisten the lymph, before being 
applied to the abraded surface. The ivory-point is one of 
the most convenient means of vaccination, as the surface 
may be abraded with it before the lymph is applied. 

It has recently been advised that antiseptic precautions 
be exercised in performing vaccination, and although all 
of the details cannot be carried out, we have found that 
the exercise of care as regards cleanliness of the surface 
has been followed by much fewer inflammatory complica- 
tions in vaccination wounds. 

The surface to be abraded, usually the left arm below 
the deltoid, is first washed with soap and water, and then 
with a 1 : 2000 bichloride solution. Two points of this 
surface, an inch apart, are then abraded by using a knife 
which has been washed or dipped in boiling water, or by 



208 MINOR SURGERY. 

using the ivory point which has been dipped in water 
which has been boiled and cooled down. When the sur- 
face has been prepared in the manner described, the moist- 
ened virus is rubbed upon it and allowed to dry. Vacci- 
nation upon the leg, which is practised by some physicians 
to prevent the scar from showing, I think is not to be 
recommended, and I never practise it in this situation, as 
it is more difficult to keep this part at rest. 

Hypodermic Injections. The syringe used to make 
hypodermic injections is provided with a perforated needle, 
which is passed into the cellular tissue (Fig. 147). Care 
should be taken to see that the instrument and needle are 



Fig. 147. 



Hypodermic syringe and needles. 

perfectly clean before being used; they should be rendered 
aseptic by soaking them for a few minutes in boiling water 
or in a 5 per cent, carbolic solution. Hypodermic injections 
are generally made into parts in which the cellular tissue 
is abundant, and great care should be observed to avoid 
introducing the needle into a large vein or artery, as by 
neglect of this precaution serious symptoms have resulted, 
from the drug being thrown rapidly into the circulation 
instead of being slowly absorbed from the subcutaneous 
cellular tissue; the injury of superficial nerves should also 
be avoided. Care should also be taken to see that the 
solutions employed are sterilized if possible, and freshly 
made solutions should be preferred. 

To avoid using solutions for hypodermic use which 
undergo change from being kept, it will be found conve- 
nient to use the compressed pellets which are prepared by 
the manufacturing chemists, the alkaloids being com- 



HYPODERMIC INJECTIONS. 



209 



pressed with a little sulphate of sodium, which increases 
their solubility, the solution being prepared with boiled 
water just before being used. 



Fig. 148. 




^^P 




Method of giving a hypodermic injection. 



The portions of the body usually selected for hypo- 
dermic injection are the outer surface of the thighs or 
arms and the anterior surface of the forearm. In making 
a hypodermic injection the syringe is charged and the 
needle is fastened to the nozzle of the syringe; the skin 
is next pinched up and the needle is quickly thrust through 
this into the cellular tissue (Fig. 148); the syringe is then 
emptied by pressing down the piston, and when the cylin- 
der is empty the needle is withdrawn. 

Injection of Antitoxins. In the treatment of diseases such 
as diphtheria and tetanus by the injection of serum, the 



Fig. 149. 




MULFORD CO., PHILADA. 

Syringe for serum-injection. 



hypodermic method is made use of; in using antitoxin 
injections in diphtheria the dose of the antitoxin is propor- 
tionate to the age and weight of the patient as well as to the 
severity and duration of the disease. A child three years 



14 



210 



MINOR SURGERY. 



old should be given 600 to 1000 units; an adult, not less 
than 1000 units, and the injection should be repeated in 
twelve to twenty-four hours. Before employing the injec- 
tion the skin should be sterilized, and the best variety of 
syringe to employ is one holding about 20 c.c. (Fig. 149). 

It is well to have the needle connected with the syringe 
by a short rubber tube, so that the needle will not be 
broken if the patient struggles. The injections are usually 
made below the angle of the scapula or in the lumbar 
region, and the serum is introduced slowly to avoid local 
reaction. 

Exploring-needle. This consists of a fine-grooved 
needle fitted into a handle (Fig. 150), which is introduced 
into tumors or swellings to ascertain the nature of their 



Fig. 150. 




Exploring-needle. 

contents, and its use is often of service for purposes of 
diagnosis. The exploring-trocar (Fig. 151) is employed 
for the same purpose, or the needle of the hypodermic 
syringe or a fine needle attached to an aspirator may be 
used for a like purpose. When either the exploring- 
needle or trocar is employed care should be taken to see 

Fig. 151. 



^^^^= eMif1cn 



Exploring-trocar. 



that it is rendered perfectly aseptic before being used; 
otherwise its employment is not without danger, for we 
have seen the introduction of an exploring-needle into an 
effusion in a joint for diagnostic purposes followed by sup- 



SKIN-GRAFTING. 211 

puration and destruction of the joint, which subsequently 
necessitated its excision. 

Skin-grafting. This is a surgical procedure which 
may be employed to fill a gap in the tissues or to hasten 
cicatrization where large granulating surfaces are exposed, 
such as result from extensive operations and from burns. 

The operation consists in applying shavings of the epi- 
dermis or of the epidermis and cutis together, to the granu- 
lating surface and holding them in contact with it for a 
few days; the grafts often seem to disappear, but at the 
end of a few days, if the part is closely inspected, bluish- 
white points will be seen to occupy the positions at which 
the grafts were applied, which become converted iuto 
isolated cicatrices from which the healing process rapidly 
extends. To have a successful result follow the use of 
skin-grafts the surface of the ulcer should be healthy, and 
its surface as well as the'surrounding skin rendered aseptic, 
and the grafts should be applied at a number of points. 

The surface from which the grafts are to be taken should 
also be rendered aseptic, and the skin should be removed 
by scissors or by a sharp razor, or by raising the epidermis 
with a needle or with forceps, and cutting out a small por- 
tion of it with a sharp scalpel. The graft is next applied 
to the granulating surface with its raw surface in contact 
w r ith the granulations; after a sufficient number of grafts 
have been applied, a piece of sterilized protective is laid 
over them and is held in place by means of a few strips of 
isinglass plaster. A sterilized gauze dressing is next ap- 
plied, and the dressing is not disturbed for a week or ten 
days, at which time, if the grafts have taken, isolated cica- 
trices at the points where the grafts were applied will be 
found to exist. 

Thiersch's Method. In skin-grafting, according to this 
method, the surface of the ulcer is rendered aseptic, and 
all antiseptics are washed away with sterilized salt solu- 
tion. The surface of the ulcer is next curetted to remove 
soft granulations, and it is then irrigated and covered with 
protective, and a compress is applied to control all bleed- 
ing. 



212 MINOR SURGERY. 

Shavings of skin are then removed from a surface — 
which has been rendered aseptic — by means of a razor or 
section knife. Each graft should be as long and broad as 
possible, and when cut it should be floated from the section 
knife by a stream of salt solution and placed upon the pre- 
pared surface of the ulcer and gently pressed into place. 

After a sufficient number of grafts have been applied, 
strips of protective are laid over the surface of the grafts, 
and over these is placed a compress moistened with salt 
solution and covered by protective, and a few layers of 
sterilized gauze and cotton are next applied over this, and 
the dressing is held in position by a bandage. 

The dressings need not be removed for a week or ten 
days, and a second dressing should be applied in the same 
manner until the grafts have become thoroughly vitalized. 
The skin of the bellies or backs of frogs, or the hairless 
skin of young animals may be used in the place of human 
skin. 

Krause's method. Skin-grafting is sometimes accom- 
plished by immediately applying a large piece of skin to a 
raw surface to fill a gap; the graft in such cases includes 
the whole thickness of the skin, but has all of the cellular 
tissue removed from it, and should be cut one-third larger 
than the gap to be filled to allow for the shrinking after 
its removal, and is secured in position by sutures. 

Bone -grafting. This procedure is resorted to to replace 
portions of bone which have been separated, to fill up cavi- 
ties in bone, or to restore the continuity of the long bones. 
The bone to be introduced should be rendered thoroughly 
aseptic and should be placed in a sterilized salt solution at 
a temperature of 100° to 105° F. ; it may be inserted in 
one piece or broken into fragments and laid over the sur- 
face. 

When it is desired to restore the continuity of one of 
the long bones, after the surfaces of the bone have been 
exposed and rendered aseptic, a bone is removed from a 
freshly killed animal, is rendered aseptic, and fitted into 
the gap and secured to the ends of the bone by sutures. Or 
a portion of the bone may be partially separated by a chisel 



BONE-GRAFTING. 213 

and fitted into the gap, or is split into strips and packed 
into the cavity. 

In the case of parallel bones, such as the tibia and fibula, 
where there has been a loss in substance of the tibia, the 
fibula has been divided on a line with the lower end of the 
tibia, and after freshening the end of the tibia the upper 
end of the lower fragment of the fibula is shifted over to 
the tibia and secured to it by sutures. 

Bone grafting may also be very satisfactorily accom- 
plished by means of Senn's decalcified bone plates or chips 
which will be found useful in filling up the cavities result- 
ing from the extensive removals of bone in the operations 
for necrosis or caries. 

In such cases, after the cavity has been sterilized, it is 
dusted with iodoform and is then packed with bone chips; 
iodoform is next dusted over them and a piece of protec- 
tive is placed upon them. A compress of iodoform or 
sterilized gauze and bichloride cotton is next applied, and 
the dressing is held in position by a bandage. 

When bone plates are employed they are cut to fit the 
cavity, and provision should be made for drainage. 

Preparation of Decalcified Bone Chips or Plates. Take 
sections of the compact tissue of the fresh tibia or femur 
of an ox, several inches in length, remove the periosteum 
and medullary tissue, and split in pieces one-half an inch 
in width, and place them in a 15 per cent, watery solution 
of hydrochloric acid, allowing them to remain in this for 
three weeks, changing the solution daily. At the end of 
this time they should be removed, thoroughly washed and 
cut in thin strips or plates. They should then be washed 
in a weak solution of caustic potash, and placed for forty- 
eight hours in a 1 : 1000 bichloride solution. 

After this they may be kept in a solution of iodoform 
in ether, or in a 1 : 500 solution of bichloride in alcohol 
until required for use: before being used they should be 
soaked in a 1 : 2000 bichloride solution. 

Muscle-grafting and nerve-grafting are also occasionally 
resorted to to supply deficiencies in muscles or nerves, 



214 



MINOR SURGERY. 



fresh muscle or nerve tissue being employed to fill up the 
gap. 

Electrolysis. Electrolysis, or the chemical decomposi- 
tion induced by electricity, is employed in surgery to de- 
stroy morbid products, tumors, or exudations. For this 
procedure a galvanic or continuous-current battery is re- 
quired, which is provided with electrodes and needles of 
suitable shapes. In applying electrolysis to a tumor, for 
instance, the needle connected with one of the poles of the 
battery is inserted into the tumor, and the other rheophore 
is applied to the surface of the body, or two fine needles, 
carefully insulated nearly to their extremities, are con- 
nected with both poles of the battery by conducting cords; 
these are introduced into the tumor and a weak current is 
allowed to pass. The strength of the current is gradually 
increased as the operation advances; the current is passed 
for fifteen or twenty minutes, and the procedure is repeated 
at intervals of several days, until some decided change 
occurs in the tumor. 

Electrolysis has been applied with success in the treat- 
ment of aneurism inaccessible to other operative proced- 
ures, in malignant growths, in nsevi, goitres, cysts, and 
hydatids. It is at the present time the most satisfactory 
method of removing superfluous hairs from those portions 
of the body in which their presence causes disfigurement. 

Galvano cautery. Galvano-cautery batteries are con- 
structed with plates of large size, placed closely together, 

Fig. 152. 




Electrodes for galvano-cautery. 



so that the internal resistance is reduced and a current is 
quickly obtained which will keep a metallic electrode at a 
white heat. The advantage in the use of this form of 



FARADIZATION. 215 

cautery is that the electrode can be introduced into the 
various cavities of the body while cold and quickly heated 
to the desired temperature. The electrodes are made of 
various shapes and sizes, according to the object desired 
(Fig. 1 52). The galvano-cautery is applied for the same 
purpose as the actual cautery, but, as previously stated, 
its use is more convenient in the various cavities of the 
body, its action can be more easily localized, and by its 
use hemorrhage is avoided. It is frequently employed to 
destroy morbid growths in the nasal passages, the throat, 
vagina, or uterus, and also may be employed in the treat- 
ment of superficial external growths; in using it for the 
removal of growths from the mucous membrane its appli- 
cation may be rendered practically painless by previously 
thoroughly cocainizing the parts. 

Faradization. The application of electricity in this 
form is often employed in surgical affections; in cases of 
wasting of the muscles following fractures or sprains, in 
some forms of club-foot, and in lateral curvature of the 
spine the judicious use of the faradic current will often be 
found to be followed by the most satisfactory results. The 
current is applied in such a manner as to bring about con- 
traction of the affected or wasted muscles, and thus im- 
prove their nutrition. 

Franklinization. The earliest application of electricity 
in the treatment of disease was made by the use of statical 
electricity, and although it fell into disuse it has recently, 
with the perfection of modern machines, been very widely 
revived. In applying statical electricity the patient may 
be treated by insulation, or the so-called dry electric bath. 
The second method of using statical electricity is by sparks 
or shocks from a Leyden jar which is charged from the 
prime conductor of an electrical machine in motion, or by 
the electric brush. McClure states that in the static 
induced current we have a means of producing muscular 
contractions when failure results from the strongest fara- 
dic currents that can be borne by the patient. 

The Oystoscope. This is an instrument employed for 
ocular examination of the walls of the bladder, and is 



216 



MINOR SURGERY. 



one of the most important and useful of the electric-lamp 
instruments. A cystoscope consists of a beaked sound in 
which there is a telescopic arrangement by which the inner 
surface of the bladder is viewed through a small window 
of rock crystal. The lamp is inclosed in the beak of the 
instrument and throws its light through another window, 
also of crystal, upon any part of the bladder wall. For 
examining the upper part of the bladder, a separate instru- 
ment with a small reflecting prism is used. The bladder 
should contain six or eight ounces of clear urine or clear 

Fig. 153. 




Illumination of the wall of bladder by cystoscope. (Park. 



water if a proper view of the walls is to be obtained. If 
the fluid is turbid or contains blood the view is very much 
obscured ; if too little fluid be present in the bladder, the 
beak of the instrument containing the lamp is likely to be- 
come buried in the folds of mucous membrane and the 
light will be cut off, and, the mucous membrane may be 
burned. A certain amount of practice is required to use 
the cystoscope properly and to recognize the appearance 
of the mucous membrane of the bladder in health and in 
its varied morbid conditions. 



THE URETHROSCOPE. 



217 



The Urethroscope. The urethroscope consists of a 
straight metal tube provided with an obturator of hard 
rubber which projects slightly beyond the end of the tube. 
This tube is introduced into the urethra until the bladder 
is reached, when it is slightly withdrawn and the obturator 
is removed.^ The instrument is then attached to a mirror 
or an electric lamp, by which a strong light is thrown into 
the tube, and as the tube is withdrawn various parts of 
the urethra are exposed to the view of the surgeon. By 

Fig. 154. 




The urethroscope. 



means of the urethroscope a very accurate inspection of all 
portions of the urethra can be obtained. 

The Panelectroscope. This instrument, introduced by 
Leiter, consists of an electric lantern with tubes and a 
mirror. The light from a small incandescent lamp is pro- 
jected by the mirror along the tube, which is inserted into 
the part to be examined. Tubes of various sizes are 
adapted to the instrument. It is employed for endoscopy 
of the urethra, ear, pharynx, and stomach. 

p Massage. Massage consists in a variety of manipula- 
tions, such as pinching up the integuments and muscles, 
and rolling them between the thumb and fingers, in strok- 
ing or rubbing the surface with the palm of the hand from 
the periphery toward the centre, to empty the distended 



218 MINOR SURGERY. 

veins and lymphatics; rubbing the parts circularly with 
the extremities of the fingers and thumb or the palm of 
the hand, or kneading of the parts is another method of 
practising massage. Massage may also be practised by 
tapping the surface of the affected part with more or less 
force with the tips of the fingers held in a row, or with 
the ulnar border of the hand or with the palm of the hand. 
Before applying massage to an affected part, if there be a 
heavy growth of hair, it should be carefully shaved off; 
otherwise the manipulation may give the patient pain, and 
irritation of the hair follicles resulting in abscesses will be 
apt to occur. The part should also be rubbed over with 
olive oil, vaseline, or cocoa-butter before and during the 
manipulations. 

Massage is often employed with advantage in the treat- 
ment of sprains and strains in their subacute and chronic 
stages. Lucas-Championniere advocates and practises im- 
mediate and continuous massage in the treatment of frac- 
tures. It will also be found of great service in the later 
treatment of fractures involving the joints or their vicinity, 
in restoring the motion of the parts as well as in improv- 
ing the nutrition of the muscles which have become 
wasted from disuse. 

Passive Motion. This manipulation consists in alter- 
nately flexing and extending or rotating the limb to imi- 
tate the normal joint-movements. The motions should be 
carefully practised, and in cases of fracture they should 
not be undertaken until there is quite firm union at the 
seat of fracture, or if for any reason passive motion is 
made use of before this time the fragments should be 
firmly supported while it is being employed. Other forms 
of massage, such as stroking and kneading, may be em- 
ployed in conjunction with passive motion in the treatment 
of the troublesome stiffness of joints resulting from frac- 
tures, dislocations, and sprains; passive motion applied in 
this manner will often restore the function of a stiff joint 
more satisfactorily and with less pain to the patient than 
the forcible manipulations of the joint which are practised 
under an anaesthetic. 



APPLICATION OF HOT AIR. 



219 



Application of Hot Air. The employment of a con- 
tinuous hot-air bath has been recently advocated in the 
treatment of painful and partially anchylosed joints, syno- 
vitis, teno-synovitis, and chronic rheumatism. In apply- 
ing this method of treatment the limb is wrapped loosely 
in lint, and introduced into a metallic cylinder (Fig. 155), 

Fig. 155. 




Apparatus for hot-air treatment. 



the temperature of which is raised to a point about 300° F. 
The part is exposed to this temperature for three-quarters 
of an hour to one hour and at intervals of twenty min- 
utes the door is opened for a short time to allow the ingress 
of fresh air, and if the part is perspiring it is wiped dry, 
for if moisture is present upon the limb, burns are more 
likely to result. Under this form of treatment pain is 
often temporarily or permanently relieved, synovial eftu- 



220 MINOR SURGERY. 

sions disappear, and adhesions are softened and disappear. 
Clinically it has been found that the best results following 
this method of treatment have occurred in painful and an- 
chylosed joints following traumatisms, and although tem- 
porary improvement has occurred in rheumatic, gouty, 
tuberculous and gonorrhoea! affections of joints, permanent 
improvement is not so likely to result. 

The Clinical Thermometer. For clinical observations 
two thermometer scales are in general use, the Centigrade 
and Fahrenheit; the latter is the one commonly employed 

Fig. 156. 



3IRM3Q 9 5 100 5_ 110 

Clinical thermometer. 

in America and in England. This scale has a limited range 
above and below the normal bodily temperature, which is 
93 2 o Fahrenheit or 36° Centigrade. Thermometers are 
now made with a convex surface, which serves to magnify 
the column of mercury, and thus enables the observer with- 
out difficulty to note the position of the index (Fig. 156). 
The temperature of the body may be taken in the 
mouth, axilla, vagina, or rectum; the two former positions 
are those generally employed. When taken in the axilla 
care should be exercised to see that no clothing is inter- 
posed between the skin and the instrument, and when the 

Fig. 157. 




Surface thermometer. 



mouth is used for thermometric observations the patient 
should be instructed to keep his lips tightly closed and 
breathe through his nose. The thermometer should be 
kept in place for from three to five minutes. 

Surface thermometers are sometimes employed, the instru- 
ments for this purpose having bulbs of a discoid shape, or 
being drawn out in the form of a spiral or coiF(Fig. 157). 



SKIAGRAPHY. 



221 



In using this form of thermometer to determine the amount 
of variation of the surface temperature, the temperature of 
corresponding parts of the body on the opposite side and the 
general temperature of the body should be taken at the 



same time. 



SKIAGRAPHY, OR EMPLOYMENT OF THE RONTGEN 
RAYS. 

Rontgen, in 1895, while investigating the cathode rays 
as developed in Crooke's tubes, discovered the energy 
which he named X-rays. The rays are invisible, but have 



Fig. 158. 




Apparatus for taking skiagraphs. (Park.) 

great power of penetration, and pass through inany sub- 
stances which are opaque to sunlight and ordinary electric 
light. If the rays are intercepted by a body not readily 
permeable, which is placed between the Crooke's tube and 
a dry photographic plate, a shadow w T ill be formed, and an 
impression of this shadow will be formed upon the plate. 



222 



MINOR SURGERY. 



Such a shadow is known as a skiagraph. The fluoroscope 
consists of a fluorescent screen which is so placed that 
the rays emanating from the Crooke's tube and passing 
through any intercepted substance to be studied are re- 
flected directly upon it. If the body is more or less 
resistant, the observer can see it clearly through the skin 
and subcutaneous tissue. 

Fig. 159. 







Skiagraph of fracture of both bones of the forearm. 



The time of exposure to the rays varies with the strength 
of the current and the thickness of the tissues. The ex- 



SKIAGRAPHY. 



223 



posure is usually from three to fifteen minutes. The tube 
should not be placed too near the surface of the body, and 
the exposures should be as short as possible. 



Fig. 160. 




Skiagraph of bullet in knee-joint. (Willard.) 



There occasionally develops after the use of the X-rays 
a peculiar disturbance of the tissues, probably trophic in 
nature, which is known as an X-ray burn. The skin, 
several weeks after exposure to the rays, may become 
ulcerated, the nails may be lost, and a very intractable 
form of ulceration or gangrene develop. 



224 



MINOR SURGERY. 



The X-rays are of great value in locating foreign bodies, 
such as needles, pins, bullets, pieces of glass. They are 
also employed with advantage in locating mineral calculi 
in the bladder, ureter, and kidney. They are also of great 



Fig. 161. 




Skiagraph of fracture of tibia and fibula. 



value in detecting the presence of fractures and disloca- 
tions. In fractures about the joints, epiphyseal separa- 
tions, and ununited fractures, their use has proved most 
satisfactory. Skiagraphs of a fracture are shown in Figs. 



ANESTHETICS. 



225 



159 and 161, of a bullet in the knee-joint in Fig. 160, 
and of an epiphyseal separation of the humerus in Fig. 
162. 



Fig. 162. 




Skiagraph of separation of upper epiphysis of the humerus. 

ANAESTHETICS. 

The substances which are employed at the present time 
to produce either local or general anaesthesia are ice, 
cocaine, ethyl chloride, rhigolene, nitrous oxide, chloro- 
form, ether, and ethyl bromide. 

Local Anaesthesia. 

Cold. Local anaesthesia may be produced by the appli- 
cation of cold, either by a piece of ice or a mixture of ice 

15 



226 MINOR SURGERY. 

and salt held in contact with the part for one or two min- 
utes, or by directing a spray of rhigolene or sulphuric ether 
upon the surface of the part whose sensibility is to be 
obtunded. (Fig. 163.) 




Application of rhigolene spray. 



Chloride of Ethyl. This substance is also used to pro- 
duce local anaesthesia, and is conveniently furnished in 
glass tubes, one end of which is drawn out into a fine 
point and hermetically sealed. When used the end of the 
tube is broken off and a fine jet of ethyl is projected upon 
the surface, the warmth of the hand being sufficient to 
force the fluid from the tube. 

This form of local anaesthesia is made use of in minor 
surgical procedures, such as aspiration, the opening of 
abscesses, and the removal of superficial tumors. 

Rapid Respiration. Rapidly repeated deep inspira- 
tions kept up for a few minutes will produce insensibility 
to pain, but sensibility to contact is not obliterated. This 
form of anaesthesia may be made use of in slight opera- 
tions, such as the opening of an abscess. 

Cocaine. Local anaesthesia produced by the employ- 
ment of an aqueous solution of the hydrochlorate of 
cocaine, in strength from 1 to 4 per cent., is often made 
use of in minor surgical procedures. Solutions as strong 
as 10 or 12 percent, were formerly employed, but experi- 
ence has proved that there is always danger in the use of 
the stronger solutions of cocaine, so that it is now consid- 
ered wise not to use a solution stronger than 1 or 2 per 



ANESTHETICS. 227 

cent., as the full analgesic effect can be obtained by a solu- 
tion of this strength. Where the mucous membrane is to 
be operated upon or growths removed from it, analgesia is 
produced by brushing the surface over with the solution 
of cocaine, or by applying a compress of absorbent cotton 
saturated with the solution to the part for a few minutes; 
in mucous cavities the latter method of application will be 
found most convenient. In using a solution of cocaine to 
produce anaesthesia in operations upon the eye a 2 or 4 per 
cent, solution is dropped into the eye, and the application 
is repeated until analgesia is complete. 

In applying cocaine to the urethra a 1 to 2 per cent, 
solution is injected into the urethra, and is allowed to re- 
main for two or three minutes; more than one or two 
grains should not be injected at one time, as fatal results 
have followed the injection of larger quantities; this is 
especially the case in using cocaine in the urethra and the 
rectum, and in these situations great caution should be 
exercised in its use. 

When it is desired to produce local anaesthesia of the 
skin or deeper tissues the application of the solution of 
cocaine to the surface is not satisfactory, and it should in 
such cases be injected hypodermically into the deeper layers 
of the skin and into the cellular tissue of the parts to be 
operated upon ; to avoid multiple punctures the needle is not 
completely withdrawn from the wound, but its direction is 
changed and the solution is thrown into different portions 
of the tissues. It is well in situations where it can be 
accomplished to cut off the circulation from the part to be 
operated upon by placing around it a rubber strap or tube, 
which prevents the rapid absorption of the cocaine into 
the general blood-current. 

Corning recommends injection of cocaine by the gal- 
vanic current. The skin of the region to be anaesthetized 
is perforated by a number of fine needles, and the perfor- 
ated area is covered with several thicknesses of flannel cloth 
saturated with a 5 per cent, solution of cocaine. A layer 
of potter's clay of the consistence of bread-dough, contain- 
ing a thin sheet of copper, is placed upon the flannel and 



228 MINOR SURGERY. 

the copper plate connected by an insulated wire with the 
positive pole of a galvanic battery. The negative pole 
should consist of a broad, flat sponge wrung out in hot 
water aud held as near as possible to the positive pole 
without touching it.° The more extensive the surface to 
be anaesthetized the stronger should be the current. From 
three to six cells may be used, and the time required is 
from ten to twenty minutes. 

Some persons have an idiosyncrasy for cocaine, and 
children seem more susceptible to its constitutional effects 
than adults. 1 have seen several instances in children in 
which marked symptoms of cocaine poisoning resulted 
from the application of a 4 per cent, solution to the nasal 
mucous membrane. 

The treatment of cocaine poisoning consists in placing 
the patient in the recumbent position and the hypodermic 
injection of morphine, strychnine or ether. 

Cocaine ancesthesia may be employed with advantage in 
minor surgical operations, such as amputations of the 
fingers, circumcision, opening of abscesses, and removal of 
superficial tumors, but its utility is most marked in opera- 
tions upon the eye and upon the mucous membranes of the 
nose, throat, rectum, vagina, and urethra. Applied for a 
few minutes to the surface of an ulcer which is to be cau- 
terized, it will render the operation almost painless to the 
patient. 

Eucaine Hydrochlorate. This drug, which possesses 
the same properties as cocaine, as regards the production 
of analgesia, has recently been employed as a local appli- 
cation to mucous surfaces, and hypodermically in the 
deeper tissues to produce local anaesthesia. It has the 
advantage over cocaine that it can be used with safety in 
much larger quantities, as it is apparently free from toxic 
action. Kiessel states that 2 grammes have been injected 
without the production of toxic symptoms. It may be 
used in solutions varying in strength from 2 to 10 per 
cent., which can be sterilized by heating ; a 4 per cent, 
solution is that most usually employed hypodermically. 

Guiacol. This drug may be used for its analgesic effect, 






ANAESTHETICS. 229 

and is employed in a solution of guiacol, grains xv; alco- 
hol, 5v, or may be employed in the form of an ointment 
of guiacol, 5 parts, to vaseline, 30 parts. Or it may be 
use hypodermically in a one-tenth or one-twentieth solu- 
tion in olive oil. Its hypodermic use is not unattended 
with danger. 

Infiltration Anaesthesia. It has been shown by Lie- 
breich that the injection of simple water into the tissues 
in such a way as to produce an artificial oedema induces 
a transitory anaesthesia. 

Schleich found that the combination of a minute quan- 
tity of cocaine and morphine with a weak salt solution, 
when injected hypodermically, produced a local anaesthesia 
of longer duration. 

The anaesthesia is produced by the artificial ischaemia, 
by the pressure of the injected fluids upon the nerves, and 
by the direct action of the anaesthetic substances on the 
nerves. 

A solution of 1 part of cocaine to 1000 parts of steril- 
ized water may be used, or the following solution maybe 
employed : 

Cocaine hydrochlor gr. iss. 

Morphise hydrochlor gr. %. 

Sodii chJoridi gr. iij. 

Aquae Siijss. 

The injection should be first made into the substance of 
the skin itself, and then into the cellular tissues and deeper 
structures as desired. 

Barker recommends the following solutions for employ- 
ment in obtaining infiltration anaesthesia : Eucaine, 1 part 
to 1000 parts of sterilized water, with 8 parts of chloride 
of sodium. He also recommends elastic constriction ap- 
plied above the part, as a means of increasing the action 
of the drug. Solutions with the same freezing-point as 
the normal fluids of the body should, if possible, be used, 
as they are indifferent to the tissues; that is, they possess 
no osmotic action. 

Infiltration anaesthesia has been widely employed in 
minor surgical operations, and also may be employed in 



230 MINOR SURGERY. 

major operations, such as herniotomy and amputations, 
when for any reason a general anaesthesia is not desirable. 
In children and nervous subjects it cannot be employed 
with advantage. 

General Anaesthesia. 

General anaesthesia may be produced by the administra- 
tion of nitrous oxide gas, ether, chloroform, A. C. E. mix- 
ture, Schleich's mixture, or ethyl bromide. 

Choice of Anaesthetic. In selecting an anaesthetic the 
most important considerations are its safety and its suita- 
bility to the individual case. In point of safety nitrous 
oxide gas holds the first place; but, unfortunately, its use 
is restricted to cases in which only a few minutes' anaes- 
thesia is required. Statistics show that the mortality fol- 
lowing the administration of nitrous oxide is about 1 to 
5,250,000; of ether, 1 to 16,675; of chloroform, 1 to 
3749. Gardner's statistics show that in 22,219 chloro- 
form administrations there were 14 deaths; while in 
17,067 administrations of ether or nitrous oxide gas and 
ether, there was 1 death. It should be remembered, how- 
ever, that both ether and chloroform are employed in the 
most serious surgical procedures, while nitrous oxide gas 
is only used in trivial operations, so that many of the 
deaths attibuted to ether and chloroform may have been 
due to conditions resulting from the operations themselves. 

Nitrous Oxide Gas. This gas is administered for the 
purpose of producing anesthesia, and the apparatus best 
suited for its administration consists of a cylinder of metal 
in which the gas is compressed ; this is attached to a rubber 
bag which has a mouthpiece fastened to it; this is provided 
with a double valve, which prevents the expired air from 
passing back into the bag. The mouthpiece is adjusted 
over the mouth, and after removing any false teeth, or 
foreign bodies, from the mouth, the patient is instructed 
to take deep, full breaths, and in from one-half to one 
minute the face becomes congested and dusky, and the 
breathing becomes stertorous, indicating that the patient 
is fully under the influence of the gas. The anaesthesia 



ANESTHETICS. 231 

from nitrous oxide cannot be prolonged for more than a 
few minutes, so that it can only be employed in operations 
which take a short time for their performance, such as the 
extraction of teeth and the opening of abscesses. Unfor- 
tunately, it cannot be used in the reduction of fractures or 
dislocations, as it does not produce complete muscular re- 
laxation. In England nitrous oxide is frequently used to 
produce anaesthesia, and when this result is accomplished 
the anaesthesia is kept up by the administration of ether 
by the employmeut of a special apparatus devised for this 
purpose. Nitrous oxide gas is most commonly employed 
iu dental surgery to produce anaesthesia for the removal of 
teeth, but is also occasionally employed in minor surgical 
operations; but from the fact that the apparatus for its 
administration is a bulky one, its use is not so convenient 
as ether or chloroform, and in this country it is not much 
employed iu general surgery. 

Nitrous oxide gas may also be administered by the open 
method, or by an open inhaler resembling in structure that 
of Allis. The gas, being heavier than the air, is introduced 
into the inhaler and falls to the bottom. Flux, who has 
employed this method of administration in a number of 
cases, claims that by its employment excitement, stertor, 
lividity, struggling and convulsive movements are done 
away with. 

Ether. Sulphuric ether is one of the most widely em- 
ployed substances in surgery to produce anaesthesia; it is 
probably the safest of all anaesthetics, except nitrous oxide 
gas,^tnd-4or-this reason should be given the preference 
over all others. 

Preparation of Patient. A patient should be prepared for 
the administration of ether by not allowing him to have 
any solid food for at least six hours before its inhalation; 
he should be in the recumbent posture, and any garments 
about the chest or neck should be loosened so that the 
respiratory movements are not interfered with. The sur- 
geon should also see that any false teeth or foreign bodies 
which may be present in the mouth are removed before 
the administration of the drug is begun. As the vapor of 



232 MINOR SURGERY. 

ether often causes irritation of the mucous membrane of 
the lips and nasal passages, it is well to anoint these parts 
with a little vaseline or cold-cream before administering 
the ether. 

Some surgeons recommend that the stomach, if it con- 
tains food, should be washed out by means of the stomach- 
pump, and insist upon this washing out of the stomach 
before operation in cases of intestinal obstruction, as the 
stomach may contain stercoraceous matter which may be 
drawn into the respiratory passages if vomiting occurs, and 
cause aspiration pneumonia. 

It should also be borne in mind that the vapor of ether 
is very inflammable, and that it is heavier than the air, so 
that lights brought near the patient while being etherized 
should be held at a higher level than the ether-can or 
inhaler. 

The anaesthetizer should always listen to the patient's 
heart before giving an anesthetic; this enables him to de- 
tect any irregularity in its action, and at the same time has 
a good moral effect upon the patient, especially if he can 
assure him that he is in good condition to take the anaes- 
thetic. 

It is also well to have another physician present during 
the administration of a general anaesthetic, as unforeseen 
difficulties occasionally arise. There should always be at 
hand tongue forceps, instruments with which tracheotomy 
may be performed if necessary, also nitrite of amyl, digi- 
talis, strychnine, and a hypodermic syringe. 

In debilitated patients or those who are weak from the 
loss of blood the administration of half an ounce to an 
ounce of whiskey from fifteen to thirty minutes before the 
anaesthetic is given is often advisable. 

The person instructed with the administration of the 
anaesthetic should watch the patient closely, and should not 
have his attention diverted by the operation; he should 
carefully observe the pulse, respiration, and color of the 
patient's face, and be ready to withdraw the anaesthetic 
upon the development of any symptom of danger, and to 
treat such symptoms should they arise. 



ANESTHETICS. 



233 



An anaesthetic should never be given to a woman with- 
out the presence of a third person, as in some cases these 
agents give rise to erotic dreams, and it may be difficult 
to disabuse the patient's mind of the idea that an assault 
has been committed unless the evidence of eye-witnesses 
at the time of the anesthetization can be brought forward 
to prove that such was not the case. 

Ether produces more irritation of the respiratory tract 
than chloroform, and administration of the former anaes- 
thetic is sometimes followed by the development of bron- 
chitis, pulmonary congestion, or pneumonia. These com- 
plications are less likely to occur if care is taken to avoid 
the administration of ether in patients who are suffering 
from bronchial irritation, and to see that a patient who 
has taken ether is not exposed to draughts and is not 
allowed to go out into the cold or moist air immediately 
after taking the anaesthetic. 

Administration of Ether. In the administration of ether 
a towel folded into a cone or one of the various ether 
inhalers may be employed. 
The best of these is AlhVs 
inhaler, which consists of a 
metallic framework covered 
with leather or a nickel- 
plated case, which carries a 
number of folds of a roller- 
bandage, giving a large sur- 
face for the rapid evapora- 
tion of the drug (Fig. 164). 

If a towel folded into a 
cone is used, a few layers of 
stiff paper interposed between 
the outer layers of the towel 

will keep the cone in shape A m S 's ether inhaler. 

and will prevent the evap- 
oration of the ether from its external surface. 

For the administration of an anaesthetic the patient 
should be in the recumbent posture and the head should 
be turned to one side, as in this position mucus is less apt 



Fig. 164. 




234 MINOR SURGERY. 

to collect in the pharynx and interfere with the breath- 
ing- 

In administering ether two to four drachms of ether are 
poured into a cone or inhaler and placed over the nose and 
mouth of the patient. He is then requested to take deep 
breaths, or to blow the ether away, which latter procedure 
causes him to take deep inspirations. In the beginning of 
etherization the patient will resist the inhalation much 
less if the ether is given slowly with a plentiful admix- 
ture of air. The first effect of the inhalation of ether is 
to produce acceleration of the pulse and respiration; the 
mucous membrane of the air- passages is irritated, and 
coughing often occurs; there is also in this stage a dispo- 
sition to muscular movements, and it is frequently neces- 
sary to restrain the patient; the brain is also excited, and 
the patient is apt to cry out. These symptoms call for a 
continuance of the administration of the ether, and not for 
its withdrawal. To avoid the irritation of the mucous 
membrane of the air-passages during the administration 
of ether, it has been suggested that the nasal mucous mem- 
brane be sprayed with a 2 per cent, solution of cocaine just 
before administration of the anaesthetic, and this spraying 
should be repeated every half hour while the anaesthetic 
is used. By the use of cocaine in this manner the nasal 
reflexes are diminished, the stage of excitement is short- 
ened, the sense of suffocation is diminished, and vomiting 
is less likely to occur. Succeeding the stage of excite- 
ment, if the ether be pushed, profound anaesthesia takes 
place, as is evidenced by the loss of consciousness, relaxa- 
tion of the muscular system, moist skin, loss of special 
senses, contracted pupils, and slow and deep respiration, 
tending to become stertorous. When the conjunctiva is 
insensitive to the touch of the finger, anaesthesia is usually 
profound. When the anaesthesia is complete the amount 
of ether inhaled should be diminished, and the patient 
given only so much as will keep him well under its influ- 
ence. It is surprising how small a quantity of ether the 
careful and watchful anaesthetizer will require to keep the 
patient fully under its effects for a very considerable time. 



ANAESTHETICS. 235 

The time required to produce anaesthesia by ether varies 
in different cases : anaesthesia is produced in children in a 
few minutes; in adults, from ten to twenty minutes are 
usually required; drunkards and those who have taken 
ether frequently require a larger amount of ether, and take 
a longer time to come under its influence. When the ad- 
ministration of the drug is stopped the patient may con- 
tinue for some time in an unconscious condition, resem- 
bling a quiet sleep, or he may awake and exhibit more or 
less symptoms of cerebral excitement. 

First Insensibility from Ether. There often exists in the 
early course of the administration of ether a stage of pri- 
mary anaesthesia, which lasts for a minute or more, and 
which may be taken advantage of to perform such a minor 
surgical operation as the opening of an abscess, the reduc- 
tion of a dislocation or fracture, or the extraction of a 
tooth. The recovery from this condition is usually very 
prompt, and is not followed by nausea or the after-effects 
which attend the prolonged administration of ether. 

Accidents During Etherization. During the administra- 
tion of ether, particularly in the early stage, the patient 
may suddenly stop breathing, the face at the same time 
becoming cyanosed. This condition calls for the with- 
drawal of the ether, and if an inspiratory effort does not 
quickly follow, pressure should be made upon the front of 
the chest, and when this is relaxed, a deep inspiration 
usually takes place, and no further difficulty is experi- 
enced. This condition should not be confounded with the 
very common effort of holding the breath, the latter occur- 
ring with the chest fully expanded, the former with the 
chest empty. 

Vomiting may occur during etherization, and the vom- 
ited matter may accumulate in the pharynx or the mouth, 
and obstruct the breathing, or may enter the larynx or 
trachea and cause a like result. Vomiting is more apt 
to take place if solid food has been taken shortly before 
the administration of the anaesthetic. If this accident 
occurs and interferes with breathing, the jaws should 
be opened and the head turned to one side, and the 



236 MINOR SURGERY. 

vomited matter will usually escape without difficulty. If, 
however, food has entered the larynx, and is not ejected 
by coughing, it will be necessary to perform tracheotomy 
promptly, and hold the tracheal wound open, or to intro- 
duce a tube and practice artificial respiration. The breath- 
ing may also be obstructed by the accumulation of mucus 
and saliva in the pharynx. This is less likely to occur 
if the head is kept to one side during the administration 
of the drug; if it occurs, the head should be turned to one 
side, the jaws opened, and the material removed by small 
sponges or pieces of gauze fixed to sponge-holders. 

The tongue may fall backward and obstruct the breath- 
ing when muscular relaxation is complete during anaesthe- 
sia; this accident is also less likely to occur if the head is 




Pushing the jaw forward. 

kept on one side during etherization. If asphyxia results 
from falling back of the tongue, it should be brought for- 
ward by placing the fingers on each side beneath the angles 
of the inferior maxillary bone, and pushing the jaw for- 
ward, at the same time over-extending the neck by bending 
the bead backward (Fig. 165), or the mouth should be 
opened and the tongue drawn forward by tongue forceps. 
Either of these manipulations is usually sufficient to re- 
establish the respiratory movements. 

If, however, in any of these forms of mechanical as- 



ANAESTHETICS. 237 

phyxia respiratory action is not promptly restored, some 
form of artificial respiration should be promptly resorted 
to, either Laborde's, Silvester's, Howard's, or forced res- 
piration, and of these Laborde's method, by rhythmical 
traction of the tongue, and Silvester's have yielded the 
most satisfactory results. Efforts at resuscitation in these 
cases should be persevered in for at least half an hour, as 
apparently hopeless cases have been saved by persistent 
use of these means. 

Failure of respiration may also occur from paralysis of 
the respiratory centres, or spasm of the respiratory muscles; 
the former may occur from an overdose of the anaesthetic, 
or from intercurrent asphyxia, syncope, or morbid states 
of the respiratory system. 

Spasmodic respiratory failure may occur before complete 
anaesthesia, and is liable to arise in muscular and emphy- 
sematous subjects. Respiratory failure from either of these 
causes should be promptly treated by artificial respiration 
and the hypodermic use of strychnine, atropine, or digi- 
talis. 

After-effects of Ether. After complete anaesthesia from 
ether nausea and vomiting are very commou, and both are 
more apt to follow in case the patient has taken food 
shortly before the administration of the anaesthetic. They 
may last for only a short time, or may persist for hours. 
If persistent, the swallowing of a few mouthfuls of hot 
water will often relieve the condition, or the administra- 
tion of cocaine hydrochlorate, grain one-quarter, with 
crushed ice, repeated two or three times, or the use of 
crushed ice with champagne or brandy, may be followed 
by satisfactory results. The inhalation of the fumes of 
vinegar will often prevent nausea and vomiting, the vine- 
gar being poured upon a towel or a piece of gauze, which 
is held over the mouth and nose of the patient, and it should 
be applied as soon as the administration of the ether is 
stopped; it should be used continuously for some time to 
be followed by the best results. 

Chloroform. A patient is prepared for the administra- 
tion of chloroform as in the case of ether, the same pre- 



238 MINOR SURGERY. 

cautions being taken as regards the removal of false teeth 
or foreign bodies from the mouthy and to see that the cloth- 
ing about the chest and neck does not restrict the circula- 
tion or respiratory movements. Chloroform is certainly a 
much more dangerous anaesthetic than ether, and although 
it is widely used in the British Islands and upon the Con- 
tinent, it is not extensively used in this country except in 
certain districts — as in the southern and southwestern dis- 
tricts of the United States, and here its use is followed by 
fewer fatalities than in the northern districts, so that it is 
possible that its use is safer in warm climates. Clinical 
experience has demonstrated the fact that chloroform can 
be used in aged and very young subjects and in puerperal 
patients with comparative safety; deaths from chloroform 
are more common in the middle period of life. It is also 
to be preferred to ether in patients suffering from emphy- 
sema of the lungs, bronchitis, and vascular degeneration 
of the kidneys. It is also employed by some surgeons 
instead of ether in operations upon the mouth when the 
actual cautery is employed, on account of its less inflam- 
mable character. 

Considerable diversity of opinion exists among different 
observers as to whether death resulting from chloroform 
is due to failure of the heart or failure of the respiration, 
and each has brought forward a large amount of evidence 
to prove his views correct. Although it has been demon- 
strated that chloroform is a direct depressant and para- 
lyzant to the heart-muscle or its contained ganglia, and 
that cardiac dilatation of varying degrees may be brought 
about by the administration of chloroform, yet clinical 
experience shows that paralysis of the respiratory centres 
is probably the most important factor in causing death 
during chloroform anaesthesia, for circulatory failure in 
these cases is due to embarrassed or suspended breathing, 
and the only method of treatment which has been found 
of value is that which tends to bring about respiratory 
action — namely, some one of the various forms of artificial 
respiration. 

Chloroform is more dangerous in the earlier stages of 



ANAESTHETICS. 



239 



Fig. 166. 



the administration, and the gravity of the operation ap- 
pears to have little effect in increasing its danger, as sta- 
tistics show that the greatest number of fatalities have 
occurred in minor surgical procedures, such as extracting 
teeth, amputation of the finger, reduction of dislocations, 
and opening abscesses. 

Administration of Chloroform. Chloroform is adminis- 
tered by pouring a drachm of the drug upon a folded 
towel, which is first held a few inches from the mouth and 
nose, and gradually brought nearer, but is not allowed to 
come in contact with the face, as from its local irritating 
action it will blister the surface; the lips and anterior 
nares should be anointed with vaseline. 

The ansesthetizer should remember that one of the dan- 
gers in the administration of chloroform is the risk of too 
great concentration of its vapor, so that 
he should see that a sufficient admixture 
of atmospheric air takes place. 

Chloroform may also be administered 
with Esmarch's inhaler, which consists 
of a wire frame covered with gauze (Fig. 
166). 

Various inhalers have been devised 
to regulate the amount of chloroform 
administered and to secure the proper 
admixture of atmospheric air, and the 
best of these is probably Mr. Clover's 
apparatus. 

Profound chloroform anaesthesia is 
manifested by insensibility of the con- 
junctiva to the touch, absence of the 
reflexes, complete muscular relaxation, 
and, usually, contracted pupils. When 
this stage is reached the inhalation should be stopped, and 
after this time only so much chloroform should be admin- 
istered as is sufficient to keep the patient fully under its 
influence. 

Complete anaesthesia should be produced before any 
operation is begun; if undertaken before that time, syn- 




Esmarch's inhaler 



240 MINOR SURGERY. 

cope may be produced by reflex inhibition of the heart. 
If convulsive movements take place before the patient is 
fully anaesthetized, and the face becomes cyanosed, the 
inhalatation should be discontinued until these symptoms 
disappear. The pupils should also be carefully watched, 
to see if they respond to light or if they are contracted. 
If the anaesthesia is not complete, insensibility to light or 
wide dilatation is a sign of danger which calls for the 
removal of the anaesthetic and active treatment to stimu- 
late the circulation and respiration. If the inhalation of 
chloroform has been stopped and is again in a short time 
resorted to, it should be given very carefully and slowly, 
for syncope may suddenly develop from the fact that the 
heart or the respiration may feel the effect of the previous 
use of the drug. 

Accidents During Chloroform Anaesthesia. Mechanical as- 
phyxia may occur during anaesthesia produced by chloro- 
form, as well as that by ether, by the obstruction- of the 
respiratory passages by blood, mucus, foreign bodies, or 
the tongue falling backward over the epiglottis. These 
accidents should be treated in the same manner as similar 
accidents occurring during etherization. 

Death during the administration of chloroform may 
result from cardiac syncope or from respiratory arrest, 
and the dangerous symptoms develop so rapidly that the 
greatest promptness is required to meet them. The per- 
son administering chloroform should constantly watch 
both the pulse and the respiration, and should not for a 
moment have his attention diverted from the patient; 
great vigilance is here, if possible, more important than 
during the administration of ether. 

Respiratory Arrest. During chloroform anaesthesia 
paralysis of the respiratory centres may occur, giving rise 
to respiratory arrest. If this dangerous symptom appears 
the patient's head should be lowered and artificial respi- 
ration should be promptly employed to re-establish the 
respiratory function. 

Cardiac syncope developing during the administration 
of chloroform, manifested by pallor, fluttering or arrested 



ANESTHETICS. 241 

pulse, and cessation of respiration, should be treated by 
lowering the patient's head, or inverting the patient, the 
use of a rapidly interrupted electric current, the hypo- 
dermic injection of digitalis, atropine, or strychnine, and 
the employment of artificial respiration, either Silvester's, 
the direct method, or Laborde's method, and, as in cases 
of threatened death from ether, the treatment should not 
be desisted from for some time, as by persistent employ- 
ment of these means apparently hopeless cases have been 
resuscitated. 

Ether and Chloroform. The production of anaesthesia 
by the administration of ether followed by chloroform, as 
recommended by Hewitt, has been employed in a large 
number of cases with satisfactory results. In producing 
anaesthesia by this method, ether is first given until anaes- 
thesia is produced, and the anaesthetic effect is then kept 
up by the administration of chloroform. Hewitt considers 
it advisable in this method of anaesthesia to let the patient 
come up slightly, so that there is conjunctival reflex before 
the chloroform is substituted, and also advises that the 
operation should not be undertaken until the change has 
been made. 

The A.-O.-E. Mixture. This mixture, which consists 
of 3 parts of chloroform, 1 part of ether, and 1 part of 
alcohol, has been employed by some surgeons in the place 
of ether or chloroform, with the idea that the dangers of 
chloroform are diminished by its combination with ether 
and alcohol. Clinical experience, however, has not proved 
this view to be correct. If administered with as much care 
as chloroform, its administration is accompanied with the 
same safety. It should be administered upon a towel or 
inhaler in the same manner as chloroform, and the patient 
should be watched as carefully during its inhalation as 
during the administration of the latter drug, and any com- 
plications occurring should be treated in the same manner 
as those arising during the use of chloroform. 

Schleich's Anaesthetic Mixture. Schleich has recently 
introduced an anaesthetic mixture w r hich he considers safer 
than ether or chloroform. He maintains that the absorp- 

16 



242 MINOR SURGERY. 

tion of a general anaesthetic is chiefly regulated by the 
boiling-point or point of maximum evaporation of the 
anaesthetic. An anaesthetic is unsafe in direct proportion 
to the amount absorbed, and the lower the boiling-point 
of the anaesthetic the less is absorbed; hence an anaesthetic 
to be safe should have a low boiling-point. A safe anaes- 
thetic is one in which the point of maximum evaporation 
is near the temperature of the patient, so that as much of 
the anaesthetic will be exhaled upon expiration as is inhaled 
on inspiration. Schleich employs three mixtures. The first 
contains by volume chloroform, oiss; petroleum ether, §ss; 
sulphuric ether, gvj. The second contains chloroform, §iss; 
petroleum ether, 5ss; sulphuric ether, 5v. The third con- 
tains chloroform, 5j; petroleum ether, §ss; sulphuric ether, 
5ij, 3iiss. This anaesthetic can be administered upon a 
towel or inhaler. It is claimed that by the use of these 
anaesthetic mixtures little excitement is produced and cya- 
nosis rarely occurs; that there is no hypersecretion of 
mucus and no consecutive bronchitis or pneumonia, and 
that the anaesthetic state is quiet, reaction is rapid, and 
vomiting occurs in less than half the cases. 

Bromide of Ethyl. This drug was introduced as an 
anaesthetic some years ago, but as a number of deaths fol- 
lowed its use, it was abandoned. The time required to 
produce anaesthesia is shorter than for ether, but there is 
often induced violent muscular spasm, which renders it an 
unsuitable anaesthetic in many cases. 

Bromide of ethyl has again been revived as an anaes- 
thetic, but clinical experience has found that its use is not 
devoid of danger, that it is not as safe an auaesthetic as 
ether, and that it possesses no advantages in point of safety 
over chloroform. When used it should be administered by 
pouring a drachm or two upon an inhaler or a towel, and 
the patient should be watched with the same care as dur- 
ing the administration of chloroform. 

Oxygen Gas with Ether or Chloroform. Ether and 
chloroform have recenly been administered with oxygen 
gas, and this seems to be a useful addition to our methods 
of producing anaesthesia by these anaesthetics. 



ANAESTHETICS. 243 

The combination of ether vapor and oxygen forms a 
highly explosive mixture, so that care should be exercised 
not to bring a flame near the patient during its administra- 
tion. Chloroform when mixed with oxygen does not form 
an explosive mixture. In employing these combinations 
to produce anaesthesia the patient is first allowed to inhale 
a small amount of ether or chloroform from an inhaler, 
and a tube connected with a receiver and wash bottle is 
introduced into the inhaler, and the oxygen gas is then 
turned on, so that the patient is allowed to inhale at the 
same time the vapor of the anaesthetic and oxygen gas. 

Special forms of apparatus are also furnished in which the 
gases are mixed before being introduced into the inhaler. 

By the administration of oxygen gas with the anaes- 
thetic substance cyanosis is less likely to develop, acci- 
dents are more rare, and it is claimed that vomiting is 
often entirely avoided, and that the patient recovers much 
more promptly from the condition of anaesthesia. 

After-effects of Anaesthesia. Nausea is not common 
after chloroform anaesthesia. The treatment of this con- 
dition following etherization has been previously described. 
The temperature is usually notably lowered by anaesthetics, 
so that it is always well to apply artificial heat and keep 
the patient well covered. A form of mental disturbance 
known as confusional insanity is often attributed to the use 
of anaesthetics, but, as it does not usually develop until 
some time, often two or three weeks, after their employ- 
ment, H. C. Wood is of the opinion that the relation be- 
tween the mental symptoms and the anaesthesia has not 
been clearly proved in these cases, and that it is rather the 
outcome of a peculiar depression of the cerebral cortex 
produced by the shock of the operation itself, or by the 
emotional strain due to the surgical illness. This view 
seems to be confirmed by the fact that many of the cases 
of emotional insanity which are observed follow injuries 
in which no anaesthetic has been given. Albuminuria and 
glycosuria may follow the administration of ether or chlo- 
roform, but are usually only temporary conditions. 

Paralysis of the nerves of the brachial plexus may fol- 



244 MINOR SURGERY. 

low prolonged anaesthesia when the arm is drawn high 
above the head, and is not due to the anaesthetic, but re- 
sults from stretching of the nerves over the head of the 
humerus or their compression between the clavicle and the 
first rib. 

TRUSSES. 

A truss for the palliative treatment of hernia is a 
mechanical contrivance with one or more pads and a 
strap; these are held in position by a spring to which they 
are attached, which holds the pad in contact w T ith the skin 
over the hernial opening. 

They are usually applied in cases of reducible and some- 
times in irreducible herniae, and are used in the treatment 
of herniae at all ages; in infants and young children the 
continued use of a properly fitting truss is often followed 
by a radical cure of the hernia. 

Trusses are made with steel or rubber springs and with 
pads of wood, rubber, celluloid, or horsehair, covered with 
chamois, and their shape and the pressure which they 
should exert vary with the variety of hernia for which 
they are applied. 

A firm compress applied over the inguinal canal or 
crural ring, secured in position by a firmly applied spica- 
of-the-groin bandage, forms a very satisfactory temporary 
means of preventing the descent of a hernia. 

A properly fitting truss should be worn without dis- 
comfort to the patient — that is, should not make too much 
pressure upon (he skin at the points where the pads are 
applied, and should absolutely prevent the descent of the 
hernia. In testing the adequacy of a truss, after applica- 
tion, to prevent the escape of the hernia, the patient should 
be instructed to separate his legs, bend forward over the 
back of a chair, and cough or strain deeply; if this does 
not bring the hernia down, its control of the rupture may 
be considered satisfactory. 

Trusses should be applied after the complete reduction 
of the hernia, while the patient is in the recumbent pos- 



TRUSSES. 



245 



ture. When first applied the truss should be worn both 
during the night and day, and if the skin becomes tender 
at the points of pressure, it should be sponged with alcohol 
and alum, then dried and dusted with powdered starch or 
lycopodium. Patients at first sometimes complain of dis- 
comfort in wearing a truss, but they soon become accus- 
tomed to its presence. After a truss has been worn for 
some time its use at night, while the patient is in bed, 
may be dispensed with, but the patient should not remove 
it until he is in bed in the recumbent posture, and he 
should reapply it before he rises in the morning. In chil- 
dren it is better to have the truss worn continuously, and 
if it is removed for bathing the nurse should be instructed 
to place her finger over the ring to prevent the descent of 
the hernia until the truss is reapplied. In applying trusses 
to male children care should be taken not to make pressure 
upon an undescended testicle. 

Trusses for Inguinal Hernia. In measuring a patient 
for this form of truss the circumference of the body mid- 
way between the crest of the ilium and the great trochan- 
ter should be taken, and the distance from the symphysis 



Fig. 167. 



Fig. 168. 




Truss for inguinal hernia. 



Hood's truss. 



pubis to the anterior superior spinous process of the ilium 
may also be given, as half of this distance corresponds to 
the position of the internal abdominal ring. In reducible 
inguinal hernia the truss-pressure should be exerted upon 
the inguinal canal and directly backward. To control this 
variety of hernia a single-spring truss (Fig. 167) may be 
employed, or the use of a truss having a double spring with 



246 MINOR SURGERY. 

flat pads on each side of the spine attached to the springs, 
and a smaller pad over the inguinal canal on the unaffected 
side, with a full pad on the side of the hernia, will often 
be found most satisfactory. This, which is known as 
Hood's truss, is one which will be found a very satisfacrory 
instrument both in inguinal and femoral hernia (Fig. 168). 

Trusses for Femoral Hernia. In measuring a patient 
for this variety of truss, the circumference of the body mid- 
way between the crest of the ilium and the great trochan- 
ter should be taken; the distance of the saphenous opening 
from the symphysis pubis, as well as from the anterior 
iliac spine, should also be taken. In reducible femoral 
hernia the truss-pressure should be directed backward 
against the femoral canal, and the pad should be large 
enough to make pressure upon the adjacent tissues through 
which the hernia passes, as well as upon the relaxed tissues 
covering the femoral canal. As in inguinal hernia, either 
a single or a double spring truss may be employed (Fig. 
169). 

In applying a truss for femoral hernia, care should be 
taken to see that the pad does not rest upon the pubis, 
and thus remove the pressure from the crural ring and 
adjacent tissues and prevent the proper control of the 
hernia. 

Trusses for Umbilical Hernia. In measuring a patient 
for this variety of truss, the circumference of the body 
over the umbilicus should be taken. 

Fig. 169. Fig. 170. 







Hood's truss for femoral hernia. Truss for umbilical hernia. 

In reducible umbilical hernia the truss- pressure should 
be directed backward, and the pad should bear rather on 
the tendinous margins of the ring than on the hernial 
opening. A truss for this variety of hernia should have 



CATHETERS AND BOUGIES. 247 

a flat or slightly convex pad, which is held in position 
over the umbilical ring by means of springs having coun- 
ter-pads on either side of the spine attached to their ex- 
tremities; these are fastened together by a strap (Fig. 170). 

A simple and satisfactory truss for umbilical hernia in 
infants consists of a penny covered by adhesive plaster, or 
a small flat compress of linen, held over the umbilical ring 
by one or two strips of adhesive plaster about two inches 
in width, or by a broad strip of perforated rubber adhesive 
plaster, and should be applied so as to covet in about the 
anterior two-thirds of the body. A penny, or a small, flat 
compress of linen, will be found much more satisfactory than 
the conical rubber or cork pad which is often recommended. 

Trusses for Irreducible Hernia. The application of 
a truss to this variety of hernia secures the hernia from 
injury and prevents its further protrusion. Such trusses 
are secured in the same way as those for reducible hernia, 
but the pads are made concave or cup-shaped, or may 
have an air-cushion or water-cushion attached to the pad. 



CATHETERS AND BOUGIES. 

Catheters are hollow tubes, made either of metal, India- 
rubber, or other flexible substances. 

Sterilization of Catheters and Bougies. To avoid 
infection of the bladder it is important that catheters and 
bougies should be thoroughly sterilized before being intro- 
duced. Metallic catheters and bougies are best sterilized 
by boiling. Rubber instruments may be sterilized in the 
same manner, but repeated boiling destroys them, so that 
the latter should be carefully washed with soap and water, 
and then placed in a 1 : 1000 bichloride solution for half 
an hour, and then rinsed in sterilized water before being 
introduced. 

Recent investigations have shown that very satisfactory 
sterilization of catheters and bougies may be accomplished 
by exposing them to the vapor of paraform in a closed 
metallic box (see p. 147). 



248 



MINOR SURGERY. 



Infection of the bladder may occur from matter con- 
tained in the urethra, so that the urethra should also be 
sterilized. If it is possible the patient should pass the 



Fig. 171. 



Fig. 172. 



Fig. 173. 



Fig. 174. 




Metallic catheter. Prostatic catheter. 



French flexible Mercier's 

catheters. elbowed 

catheter. 



urine to wash out the urethra, and a solution of boric acid 
or boro-salicylic solutions should be injected before the 
instrument is passed. 



CATHETERS AND BOUGIES. 249 

To lubricate the instrument some sterilized substance, 
such as vaseline, boroglyceride, or olive oil should be em- 
ployed; any of these substances may be rendered sterile 
by heat. 

Metallic Catheters. These are made of silver, or, if con- 
structed of other metals, they should be plated with silver 
or nickel, to give them a smooth, bright surface which can 
easily be kept perfectly clean; and their shape should con- 
form to that of the normal urethra (Fig. 171). The shape 
of the metallic catheter is sometimes changed to meet cer- 
tain indications; for instance, the metallic catheter for use 
in cases of enlarged prostate is longer and has a larger 
curve than the ordinary instrument (Fig. 172). The 
metallic female catheter is shorter and has a much smaller 
curve than the instrument used for the male urethra. A 
female catheter made of glass is now frequently employed 
and has the advantage of easy sterilization. 

Flexible Catheters. The most commonly used variety of 
flexible catheter is that known as the English catheter, 
which is made of linen and shellac, and is provided with 
a stylet; it can be moulded into any shape desired by dip- 
ping it into hot water, which renders it very flexible, and, 
after moulding it to the proper curve, this can be fixed by 
immersing it in cold water, which hardens it again. 

The French flexible catheters are made of India-rubber, 
or a combination of this material with other substances. 
These instruments are conical 
toward their extremities, and FlG - 175 - 

terminate in an olive-shaped 
point; they are provided with 
one or two smoothly finished 
eyes near their vesical ex- 
tremities (Fig. 173). 

Another form of flexible 
catheter, known as the elbow- 
catheter or Mercier's catheter soft rubber catheter. 
(Fig. 174), has an angle or 

elbow near its vesical extremity ; this is often found a 
satisfactory instrument to use in cases of enlarged prostate. 




250 



MINOR SURGERY. 






A variety of flexible catheter made of soft India-rubber 
is also sometimes employed (Fig. 175). 

Catheters and bougies are made according to a certain 
scale. The English scale runs from 1 to 12; the Ameri- 
can from 1 to 20; and the French from 1 to 40. 



Fig. 176. 



Fig. 177. 



Fig. 178. 



Fig. 179. 




Bulbous or acora- Filiform bougies 
pointed bougies. 



Steel sound. 



Sound for dilating 
meatus. 



Bougies and Sounds. Bougies. These are flexible 
intruments which correspond in size and shape to the 



INTRODUCTION OF A CATHETER. 251 

English and French catheters, and beside there are the 
acorn-pointed bougie (Fig. 176) and the filiform bougie, 
which is made of whalebone or of the same material as 
the ordinary French bougie and catheter. These instru- 
ments are of very small size and can often be passed 
through strictures which will admit no other form of 
instrument (Fig. 177). 

Sounds. These are solid instruments usually made of 
steel with a smooth surface and plated with nickel; they 
correspond in size and have the same curve as the metallic 
catheter; the handle is flattened to allow the operator to 
grasp them firmly; they are employed in the treatment of 
strictures by dilatation (Fig. 178). The sound used in 
dilatating strictures of the meatus is straight and is shorter 
than the sound employed in the treatment of urethral 
strictures (Fig. 179). A metallic sound with a larger 
curve than the ordinary sound is used for exploration of 
the bladder for calculus or tumor. 

Introduction of a Catheter. For the introduction of 
a catheter the patient may be in the standing, sitting, or 
recumbent posture, and the latter is the best in most 
cases; he should rest squarely on his back and have the 
thighs a little flexed and separated. 

Before passing a metallic catheter the surgeon should see 
that it has been sterilized, and after warmiug and oiling it 
he stands upon the left side of the patient and grasps the 
penis with the left hand, and turns it over the pubis and 
introduces the beak of the catheter into the meatus, and 
gently passes it along the urethra until its point passes 
beneath the symphysis pubis; at this point the handle is 
elevated and gently depressed between the thighs, and the 
beak will pass into the bladder (Fig. 180). 

When the prostatic region is reached difficulty is some 
times experienced in the further passage of the instrument; 
this may be overcome by introducing the finger into the 
rectum and guiding the catheter through the prostatic 
urethra, or if the prostate is found much enlarged, the 
catheter should be withdrawn, and a prostatic catheter 
(Fig. 172) should be substituted for it. 



252 



MINOR SURGERY. 



The same manipulation is made use of in passing 
metallic sounds. 

Flexible catheters and bougies are passed by grasping 
the penis and holding it in such a position that it is at a 
right angle to the axis of the body, and the catheter or 
bougie is passed into the meatus and carried th rough the 
urethra into the bladder by gently pushing the instrument 
downward. 



Fig. 180. 




Introduction of a catheter. (Voillemier.) 



In this variety of instrument, which has no curve, the 
surgeon has no means of guiding the point of the instru- 
ment, and if an obstruction is met, he should withdraw 
the instrumeut slightly and make another attempt; all 
manipulations should be extremely gentle. 



CATHETERIZATION OF THE URETERS. 253 

Passing the Female Catheter. It was formerly con- 
sidered important to pass the female catheter without 
exposing the patient. At the present time this is rarely 
done, as it is considered more important to sterilize the 
vulva and region of the orifice of the urethra to avoid 
infection of the bladder. After washing the vulva with 
soap and water, and irrigating it with boric solution or 
normal salt solution, the orifice of the urethra is exposed, 
by separating the nymphse, and the catheter is introduced 
into the bladder. 

Catheterization of the Ureters in the Female. In 
performing this operation by the direct or Kelly's method, 
the patient is placed in the dorsal position with the pelvis 
elevated or in the genu-pectoral position, and the urethra is 
dilated to admit a cylindrical speculum 12 to 15 millimetres 
in diameter. With the aid of a head mirror the interior of 
the bladder can be directly inspected. The opening of the 
ureter can be exposed by turning the speculum thirty de- 
grees to one side, and is recognized as a small depression, 
the mucous membrane being of a darker color than else- 
where. A delicate elastic or silver catheter can be intro- 
duced into this opening, and by careful manipulation may 
be passed as far as the pelvis of the kidney. By this pro- 
cedure unilateral or bilateral disease of the kidneys may 
be clearly demonstrated, as well as the condition of the 
ureters themselves. A delicate bougie passed into the 
ureters may be used to locate the position of the ureters in 
the operation of hysterectomy. Catheterization of the 
male ureters can also be practised. 

Tying the Male Catheter in the Bladder. When it 
is desirable to retain a catheter for some time in the male 
bladder, it is necessary to secure it to prevent its slipping 
out. Either a metallic or flexible catheter may be em- 
ployed, but, as a rule, the flexible instrument is the most 
comfortable to the patient and is to be preferred; there 
are several methods of securing it in the bladder. 

By one method two narrow strips of tape or two or three 
strong silk ligatures are attached to the rings at the end of 
a metallic catheter, or are securely fastened around the end 




254 MINOR SURGERY. 

of the flexible instrument; these are next brought back- 
ward, one on each side of the penis, and the skin is drawn 
forward and a strip of adhesive plaster half an inch in 
width is passed over the strings or tapes and carried three 
or four times around the body of the penis just behind the 
position of the glans penis. If the skin has been brought 
well forward before the strips have been applied, the liga- 
tures are tightened as it slips 
FlG - 18L back, and the catheter has not 

too much play (Fig. 181). 

Another method consists in 
fastening a strong silk ligature 
around the catheter just in ad- 
vance of the meatus ; the two 
ends are next brought backward 
and tied in a knot behind the 
Tying in catheter. (Bryant.) corona glandis; the ends are 

then carried around the penis 
behind the corona and tied on one side of the frsenum ; 
the foreskin is slipped forward and covers the ligatures. 

A catheter may also be secured in the bladder by tying 
the ends of the silk ligatures, which are attached to the 
instrument in advance of the meatus, to tufts of pubic hair. 
A simpler method of securing the catheter is to perfor- 
ate the free eud with a needle armed with a double ligature 
of silk or hemp ; the needle being removed, two loops are 
made of the proper length, and these are passed through 
the ends of a T-bandage, which is secured around the 
waist, the tails being brought up on either side of the 
scrotum and secured to the body of the bandage passing 
around the waist. 

In the female bladder, when it is desirable to keep the 
bladder empty, the self-retaining catheter is usually em- 
ployed, which consists of a catheter with a bulb at its 
vesical extremity, or an ordinary catheter with silk loops 
and a T-bandage may be employed in the same manner as 
in securing a male catheter. 

Irrigation of the Bladder. This procedure may be 
required in the treatment of cystitis, or in sterilizing the 



IRRIGATION OF THE BLADDER. 



255 



Fig. 182. 



bladder, and it is accomplished by passing a flexible cath- 
eter with a large eye into the bladder, or a double or two- 
way catheter may be employed. A syringe, or, better, a 
rubber bulb holding about a pint, having a nozzle and 
stopcock (Fig. 182), is filled with warm water, or with 
any medicated solution which is desired, 
and it is then attached to the free end of 
the catheter and the contents are gently 
injected into the bladder; care should be 
taken that the bladder is not too much 
distended. When the desired amount of 
fluid has been injected, it is allowed to run 
out of the catheter, and the procedure may 
be repeated until the solution comes away 
perfectly clear. 

The bladder may also be irrigated with- 
out using a catheter, the resistance of the 
compressor muscle of the urethra being 
overcome by the pressure of a column of 
water. The patient sits in a chair and a 
rubber or glass nozzle with a large bul- 
bous tip, which closely fits the meatus, is 
inserted into it; the nozzle is connected by a rubber tube 
with a reservoir containing the fluid for irrigation. The 
reservoir is raised to a height of three to six feet above 
the patient. He is directed to take deep inspirations, and 
soon the bladder becomes filled with water, when the noz- 
zle is removed, and the patient empties the bladder natu- 
rally. In some cases a little time is required before the 
column of water overcomes the resistance of the com- 
pressor muscle, or its entrance into the bladder may be 
hastened by making the patient attempt to urinate. 

Care should be taken to see that the bladder is perfectly 
emptied of the solution, and in cases of paralysis of the 
bladder gentle pressure should be made upon the abdomen 
over the pubis to accomplish this object. Solutions of boric 
acid, permanganate of potassium, and weak solutions of 
carbolic acid and of nitrate of silver are often employed 
in washing out the bladder in cases of chronic cystitis. 




Rubber bag with 
stopcock, for irriga- 
tion of the bladder. 



256 



MINOR SURGERY. 



Fig. 183. 



Urethral Injections. In the treatment of urethral 
inflammations the injection of medicated solutions is gen- 
erally made use of, and as these injections are usually made 
by the patient himself, he should be shown or instructed 
how to employ them. A rubber syringe having a conical 
nozzle and holding about two or three drachms is the best 
instrument to employ for this purpose (Fig. 183). The 
syringe having been filled with the solution, the 
patient sits upon the edge of a hard chair, with 
the thighs separated, grasps the syringe between 
the thumb and middle finger of the right hand, 
the tip of the index finger resting upon the end 
of the piston, and inserts its conical end from a 
quarter to half an inch within the meatus, which 
is held open by the thumb and finger of the left 
hand. After the introduction of the nozzle of 
the syringe the tissues should be drawn tightly 
around it, the pressure being made laterally so 
as to narrow the urethral opening instead of 
broadening it, as is the case when the compres- 
sion is in an antero-posterior direction. After 
the fluid has been thrown into the urethra in 
shape of this manner the syringe is removed, and the 
noz f£.°i patient is instructed to hold the lips of the 
syringe. meatus together for one or two minutes to pre- 
vent the escape of the fluid. 
Urethral irrigation may also be practised by means of 
gravity, a short rubber or glass tube being connected by 
a rubber tube with a reservoir containing the fluid to be 
used; the reservoir being placed slightly above the patient. 




SUTURES. 



A variety of materials are employed for sutures, such 
as silk, catgut, silver or iron wire, silkworm-gut, kanga- 
roo-tail tendon, and horsehair; the materials most fre- 
quently employed at the present time are either catgut, 
silk, or silkworm-gut, although some surgeons prefer silver 



SUTUBES. 257 

wire. Catgut and kangaroo-tail tendon are practically 
the only substances employed as sutures which are absorb- 
able; the other varieties of suture require removal after 
their application, although some sutures, such as the silk, 
when employed in subcutaneous wounds may be cut short, 
as they are apt to become encysted and produce no trouble. 
It matters little what variety of material be employed for 
suturing if the surgeon is careful to see that it is rendered 
thoroughly aseptic before being brought in contact with 
the wound. 

Suture; of Relaxation. These are sutures which are en- 
tered and brought out at some distance from the edges of 
the wound, and are employed to prevent dangerous tension 
upon the sutures which approximate the edges of the skin. 
This form of suture is employed by the use of the quilled, 
button, or plate suture. 

Sutures of Coaptation. These are superficial sutures ap- 
plied closely together, and include only the skin; they are 
employed to secure accurate apposition of the cutaneous 
surface of wounds. 

Sutures of Approximation. These are sutures which are 
applied deeply into the tissue to secure approximation of 
the deep portions of a wound; this object is accomplished 
by the use of the quilled, buried, button, or plate suture. 

Secondary Sutures. These sutures are applied when the 
surfaces of the wounds are covered by granulations, when 
the primary sutures have failed to secure apposition of the 
edges of the wound, in cases of secondary hemorrhage 
where the opening of the wound has been necessitated to 
turn out the blood-clot and secure the bleeding vessel, and 
in plastic operations where the primary sutures have failed 
to secure adhesions of the edges of the flaps. They are 
also employed with advantage in closing wounds in cases 
in which it was necessary to pack the wound with anti- 
septic gauze, or to allow haemostatic forceps to remain 
clamped upon bleeding tissues in the wound at the time of 
operation. The sutures should in such a case be intro- 
duced and loosely tied at this time, and when the packing 
or forceps is removed at the end of two or three days the 

17 



^5" 



258 



MINOR SURGERY. 



sutures are tightened so as to secure apposition of the 
edges of the wound. 

Surgical Needles. Needles for surgical use are of 
different sizes and shapes (Fig. 184); straight needles are 
the ones most commonly employed, but curved needles 



Fig. 184. 




Surgical needles. 

will be found most convenient for the introduction of 
sutures in wounds of certain locations. Hagedorn needles, 
which are flat and have sharp-cutting edges, make a nar- 
row linear wound in the tissues and are useful in some 
cases. Tubular needles are often employed in introducing 



Fig. 185. 




Mounted needles. 



sutures in wounds in which the use of an ordinary needle 
is difficult; for instance, in the operation for cleft palate, 
and for the introduction of sutures in deep wounds, a 
mounted needle will often be found very useful (Fig. 185). 
Eeverdin's needle, which consists of a handled needle with 
an eye which is closed with a slide, is useful in passing 



METHOD OF SECURING SUTURES. 



259 



deep sutures. The needle is first passed through the tis- 
sues, then threaded and withdrawn, carrying the suture 
with it. Needles should be sharp and clean and should be 
rendered thoroughly aseptic before being used. A needle- 
holder is often required for the satisfactory introduction of 



Fig. 186. 




Needle-holder. 



sutures in wounds of certain localities (Fig. 186); if this 
is not at hand the needle may be held by a pair of dress- 
ing forceps or a pair of haemostatic forceps. 

Method of Securing Sutures and Ligatures. Metal- 
lic sutures are usually secured by twisting the ends to- 
gether or by passing the ends through a perforated shot 
and clamping the shot with a shot-compressor, which 
securely fixes them. 

Sutures and ligatures of catgut, silk, silkworm-gut, kan- 
garoo-tail tendon, or horsehair are secured by tying, and 
several different knots are employed to secure them. 

Reef or Flat Knot. This is one of the best forms of knot 
to use in securing sutures or ligatures, and it is made by 
passing one end of the thread 
over and around the other 
end, and the knot thus formed 
is tightened ; the ends of the 
thread are next carried toward 
each other and the same end is 
again carried over and around 
the other, and when the loop 
is drawn tight we have formed 
the reef or flat knot (Fig. 187). 

Surgeon's Knot. This knot is 
formed by carrying one end of the thread twice around 
the other end (Fig. 188); and after tightening this loop 



Fig. 187. 




Reef or flat knot. 



260 



MINOR SURGERY. 



the same end is carried over and around the other end as 
in the case of the final knot of the reef or flat knot. The 
surgeon's knot and reef knot combined is one of the best 
methods of securing sutures or ligatures of catgut or silk, 
as the first knot is not apt to relax before the second knot 
is applied (Fig. 189). 



Fig. 188. 



Fig. 189. 




Surgeon's knot. 



Surgeon's knot, and reef knot combined. 



Granny Knot. This method of tying the ligature or 
suture should not be employed, as the resulting knot is 
not as secure as the reef knot and is apt to relax; it differs 
from the latter in the fact that one end of the thread having 
been carried across and around the other end, the knot is 
completed by carrying the same end under and around the 
other end of the thread (Fig. 190). 



Fig. 190. 



Fig. 191. 





Granny knot. 



Staffordshire knot. 



Staffordshire Knot. This is much used to secure the ped- 
icle in the removal of abdominal tumors, and is applied 
as follows : A handled-needle armed with a stout silk 
ligature is passed through the pedicle, and then withdrawn 



SUTURES. 



261 



Fig. 192. 



so as to leave a loop on the distal side ; this loop is drawn 
over the tumor and one of the free ends is passed through 
it so that one end is above while the other end is below the 
retracted loop (Fig. 191). The ends are then seized and 
drawn through the pedicle; at the same time the thumb 
aud forefinger are pressed against it until sufficient con- 
striction is made, and the ends are finally secured by tying 
as in the securing of an ordinary ligature. 

Varieties of Sutures. 

The Interrupted Suture. This variety of suture 
which is the one most usually employed in the apposi- 
tion of wounds, consists of a number of single stitches, 
each of which is entirely independent of those on either 
side. In applying this suture the surgeon holds the edge 
of the wound with the fingers or forceps and thrusts the 
needle, previously threaded, through the skin three or four 
lines from the edges of the wound. He 
then passes the needle from within outward 
through the tissues of the opposite flap at 
the same distance from the edge of the 
wound (Fig. 192). Each stitch is secured 
as soon as it is passed — by tying if a silk, 
catgut, or silkworm-gut suture be used, or 
by twisting if a silver wire suture is em- 
ployed. 

A suture may be used with a needle 
threaded on each end, in which case both 
needles are passed from within outward. 
The sutures may be secured as soon as ap- 
plied, or they may be left unsecured until a 
sufficient number have been introduced, and 
then they may be secured by tying or twist- 
ing. Care should be taken to see that they 
make no tension on the edges of the wound and that they 
are so introduced as to make the best possible apposition 
of the parts. 

Buried Sutures. In extensive and deep wounds it may 
be found necessary to introduce both deep and superficial 




Interrupted su- 
ture. (Paek). 



262 



MINOR SURGERY. 



Fig. 193. 



sutures, the former bringing about apposition of the mus- 
cles and deep fascia, the superficial layer bringing together 
the superficial fascia and skin. 

Deep or buried sutures are often employed to unice fas- 
cia, muscles, or tendons, and the best material for this 
variety of suture is either catgut, silk, silkworm-gut, or 
kangaroo-tail tendon. 

Continued Suture. This variety of suture is applied 
in the same manner as the interrupted suture, but the 
stitches are not cut apart and tied; it is made with silk or 
catgut and is secured by drawing it double 
through the last stitch and using the free 
end to make a knot with the double por- 
tion attached to the needle (Fig. 193). 
This suture is generally employed in in- 
testinal sutures, but also may be employed 
in bringing about apposition of the edges 
of wounds in tissues of loose structure. 

Subcuticular Suture. Halsted has 
introduced a suture in which the needle 
is introduced on the under surface of the 
skin on one side, and brought out just 
beneath the cut edge; it is then entered 
in the reverse direction below the epider- 
mic surface opposite; when tied it will lie 
wholly out of sight. The object of this 
variety of suture is to avoid infection of 
the wound by the skin coccus which may be introduced 
by the suture if passed from without inward. Fine silk 
or catgut should be used for this variety of suture, which 
may become encysted, absorbed, or gradually cast off after 
a few weeks. If employed as a continuous suture the 
free ends may be tied together and the suture subse- 
quently removed by cutting the loop and drawing out the 
suture from one end of the wound. 

The Twisted or Hare-lip Suture. This is a very use- 
ful form of suture where great accuracy and firmness of 
apposition of the edges of the wound are desired. It is 
applied by thrusting pins or needles deeply through both 




Continued or glover's 
suture. (Park). 



SUTURES. 



263 



lips of the wound, the edges being kept in contact over 
the wound by figure-of-eight turns with silk or wire (Fig. 
194). The ends of the pins should be cut off by pin- 
cutters after the sutures are applied, or should be protected 
by pieces of cork or plaster to prevent them from injuring 
the skin of the patient and causing him pain. 

The twisted or hare-lip suture is frequently employed 
in plastic operations about the face and in other parts of 
the body where accurate apposition of the flaps is desired. 



Fig. 194. 



Fig. 195. 





Twisted or hare-lip suture. 



India-rubber suture. 



Mattress or Quilt Suture. This suture is applied by 
carrying the needle through the two flaps and then back 
again, so that a loop is left on one side and the two ends 
of the suture project from the opposite flap. This variety 
of suture may be applied as an interrupted or as a con- 
tinuous suture; in the latter loops are made through the 
flaps on each side of the wound. 

The India-rubber Suture. This is applied by first 
passing the pins or needles through the edges of the flaps, 
and instead of the twisted figure-of-eight suture of silk, 
delicate rings of India-rubber are employed (Fig. 195). 

The Quilled Suture. In making use of this suture a 
needle armed with a double thread of wire or silk is passed 
through the tissues as in applying the interrupted suture, 
but at a greater distance from the edges of the wound. 
Into the loops on one side of the wound is inserted a quill 
or piece of a flexible catheter or bougie, and on the oppo- 
site side the free ends of the sutures are tied around a 
similar object after being tightened (Fig. 196). This form 



264 



MINOR SURGERY. 



of suture makes deep aud equable pressure along the whole 
line of the wound. In applying this suture it may be 



Fig. 196. 





Fig. 197. 



The quilled suture. (Smith.) 

found advisable in some cases to introduce a few superfi- 
cial interrupted sutures along the line of the wound to 
secure accurate approximation of the 
skin. Two small rolls of sterilized 
or antiseptic gauze may be used as 
a substitute for the quills or pieces 
of catheter, as shown in Fig. 197. 

Button or Plate Suture. This 
suture is applied by passing a needle 
armed with a double thread as in 
the case of the quilled suture, the 
ends of the suture being passed 
through the eyes of a button or 
through perforations in a lead plate 
before being threaded in the eye of 
the needle. After the suture pre- 
pared in this way has been passed 
through both sides of the wound, the 
needle is removed and the free ends 
of the suture are passed through the 
eyes of a button or the perforations in a lead plate on the 
opposite side of the wouud, and are tightened and secured 




Modified quilled suture. 
(Paek.) 



SUTURES. 



265 



(Fig. 1 98). In applying this form of sutures, small rolls of 
antiseptic gauze may be used instead of buttons, as shown 
in Fig. 199. This form of suture may be employed in deep 
wounds to accomplish the same purpose as the quilled 
suture. It allows the cutaneous margins of the wound to 
remain free from compression, and here, as in the case of 



Fig. 



Fig. 199. 





Button suture. (Smith.) Modified plate suture, using gauze pledgets. (Park.) 

the quilled suture, a few interrupted sutures may be intro- 
duced between the button or plate sutures to secure accu- 
rate apposition of the skin surfaces if desired. 

Shotted Sutures. This suture receives its name not 
from any special method of application, but solely from 
the way in which it is secured; any of the previously men- 
tioned varieties of sutures may be employed. The mate- 
rial used in applying this suture may be catgut, silver 
wire, silkworm-gut, silk, or horsehair, and after the suture 
has been passed the needle is removed, and the ends are 
passed through a perforated shot; the ends are then drawn 
upon to bring the edges of the wound in contact, and the 
shot is pressed down to the skin and clamped by means of 
a shot-compressor. The suture is then cut off flush with 
the surface of the shot. 

This method of securing sutures is especially useful in 
closing wounds in the mucous cavities, such as the vagina, 



266 MINOR SURGERY. 

rectum, and mouth, where the knot or twist of the wire 
might cause irritation of the surface or pain to the patient; 
it is also a useful method of securing sutures in plastic 
operations; it also facilitates the removal of the sutures, as 
the shot is not apt to be obscured by the swollen tissue, 
and is easily seized by forceps when the loop is divided. 

Removal of Sutures. Where sutures are buried in 
the tissues or used to approximate parts in cavities which 
are subsequently closed, such materials should be used for 
sutures as will be absorbed in a few days, or will become 
encysted and remain harmless in the tissues — such as cat- 
gut, silkworm-gut, or silk — and it is needless to state that 
sutures used with this end in view should be rendered per- 
fectly aseptic before being employed. 

Catgut sutures, when well prepared and used for sutures 
in external wounds, usually undergo absorption in from 
ten to fifteen days; the loop buried in the tissues is ab- 
sorbed and the knot may be removed from the surface with 
forceps, or it may come off with the dressings. 

The other substances, such as silk, silkworm-gut, silver 
wire, and horsehair, are removed by cutting one side of 
the loop and making traction upon the knot of the suture 
with forceps, or in the case of the wire suture, after divid- 
ing the loop and straightening out one end of it, the wire 
should be withdrawn in a curved direction. 

Sutures which are not causing any irritation should be 
allowed to remain in position until the wound is solidly 
healed. The time usually required for their retention in 
cases of aseptic wounds is from eight to twelve days. 

Lembert's Suture. Lembert's suture is used in wounds 
of the viscera covered by the peritoneum, with the object 
of bringing in contact the peritoneal surfaces. This form 
of suture is usually employed in closing wounds of the 
intestine, bladder, or stomach. 

A needle armed with a fine catgut or silk thread is 
passed, and it is better to employ a round needle, such as 
the ordinary sewing-needle, in preference to the bayonet- 
pointed needle, as there results by its use less bleeding 
from the punctures. The needle is first carried through 



INTESTINAL SUTURES. 



267 



the peritoneal and muscular coats of the intestine a short 
distance from the wound, and it is then carried across the 
wound and passed through the same portions of the intes- 
tine a short distance from the edge of the wound on the 



Fig. 200. 



Fig. 201. 




Lembert's suture. (Bryant.) 



Lembert's suture, a, serous ; b, muscu- 
lar; and, c, mucous coat. (Smith.) 



Fig. 202. 



opposite side (Fig. 200), and when the suture is tightened 
the peritoneal surfaces of the intestine are inverted and 

brought into contact with each 
other (Fig. 201); the inter- 
rupted or continued suture may 
be employed in making this 
form of suture. 

Halsted's Mattress Quilt 
Suture. This is a modifica- 
tion of Lembert's suture. The 
needle penetrates the peritoneal 
and muscular coats of the gut 
including a small portion of the 
submucosa twice on each side of 
the wound, and is then tied (Fig. 
202). 

Czerny Suture. This suture 
is applied in intestinal wounds 
by passing the needle armed with a catgut or silk thread 
through the serous membrane on one side of the wound 




Halsted's quilt suture for intestine. 



268 



MINOR SURGERY. 



of the intestine and out at the wound surface so as not to 
include the mucous membrane; the needle is then passed 
through the wound surface on the opposite side, avoid- 
ing the mucous membrane, and brought out through the 
serous membrane a short distance from the edge of the 
wound. By this suture the lips of the wound are approx- 
imated. For additional security in preventing the escape 
of the contents of the intestine and to secure approxima- 
tion of the serous surfaces a few Lembert sutures should 
be introduced. 

Circular Suture of Intestine. After division or resec- 
tion of the intestine the ends may be united by sutures. 
Interrupted Lembert sutures are usually employed. The 
sutures should first be applied at the mesenteric border, 

Fig. 203. 




Circular, or end-to-end suture ot the intestine. (Richardson.) 

and great care should be exercised to make the apposition 
close at this point. The ends of the bowel should then 
be brought together by closely applied Lembert sutures. 
If the mesentery has been divided, it should also be ap- 
proximated by sutures (Fig. 203). 

The Murphy Button. This is a mechanical contrivance 
which may be employed to secure end-to-end apposition of 



THE MURPHY BUTTON. 



269 



the divided intestine, or may be used to form a lateral 
anastomasis between the intestines or hollow viscera. 



Fig. 204. 




The Murphy button. 



The construction of the button is shown in Fig. 204. 
This method of end-to-end approximation or anasto- 



Fig. 205. 




The two portions of the Murphy button held in place by purse-string sutures. 
(Richardson.) 

mosis cau be accomplished with accuracy and with great 
rapidity. In employing the button for these purposes the 
button is separated into its two parts, and each part is 
slipped into the divided end of the intestine and secured 



270 



MINOR SURGERY. 



by a purse-string suture, and the parts are approximated by 
fastening the two portions of the button together (Figs. 
205 and 206). Where lateral anastomosis between the 
intestines, or between the intestines and another hollow 



Fig. 206. 




End-to-end union of intestine with Murphy's button. (Richardson.) 

viscus is desired, an incision is made in each organ, and 
half of the button is slipped into each opening and secured 
by a purse-string suture, and the portions of the button are 

Fig. 207. 




End-to-end approximation, button in position. (Richardson. 



then fastened together. Union of the peritoneal surfaces 
results, and the button is usually released in from ten to 
twelve days by sloughing of the included tissues, and it is 
passed by the anus. 



INTESTINAL ANASTOMOSIS. 



271 



Methods of Intestinal Anastomosis. 

Senn's Method. When it is desired to form a perma- 
nent orifice between two portions of the gut or other hol- 
low viscera, the ends of the gut are closed and an opening 
is made in each portion of the gut, into which the perfor- 
ated bone plates of decalcified bone are slipped, and the 
walls of the gut surrounding the openings are held in con- 
tact with each other by sutures attached to the perforated 
plates; this is the method devised by Senn. The manner of 
using the bone plates and sutures is shown in Fig. 208. 
To accomplish the same purpose rubber rings or perforated 
plates of rubber have been employed, also rings made from 

Fig. 208. 




WALL OF 

INTESTIN 

TURNED IN AND 

SECURED BY 

LEMBERT STITCHESI 



Diagram showing position of bone plates in intestinal anastomosis after 
resection of the bowel. (Roberts ) 



catgut, to which the sutures are attached, in the same 
manner as Senn's plates, and if catgut rings are employed 
these will be softened and dissolved in a short time so as 
to be passed without difficulty. 

Abbe's Method of Lateral Anastomosis. Portions of 
the intestinal tract more or less distant, or the intestine 
and the stomach, may be united by this procedure, thus 
permitting the contents to pass through the new opening. 
The bowel upon each side of the constricted portion is 
manipulated, so that both portions lay side by side, or, in 
case a portion of the bowel has been removed, the ends 



272 



MINOR SURGERY. 

Fig. 209. 




Lateral anastomosis. First stage of operation. (Richardson.) 
Fig. 210. 




Lateral anastomosis ; operation completed. (Richardson 



INTESTINAL ANASTOMOSIS. 



273 



are inverted and closed by Leinbert's sutures. The two 
portions of the bowel are brought side by side, and a lon- 
gitudinal cut three inches in length, opposite the mesen- 
teric attachment, is made through the coils to be united. 
The posterior edges of the incision should first be brought 
together by continuous or interrupted sutures (Fig. 209). 

The margins of the incision may be hemmed before 
uniting them. The anterior edges of the incision are next 
united by another continuous stitch, and for additional 
security a second line of interrupted or continuous sutures 
may be applied (Fig. 210). The time required for the appli- 
cation of the sutures is one disadvantage of this operation. 

Intestinal anastomosis by this method may be employed 
instead of the circular suture in wounds completely divid- 
ing the intestine and after resection of the intestine for the 
removal of growths or for stricture. 

Anastomosis or End-to-end Approximation by La- 
place's Forceps. Laplace has recently devised a forceps 

Fig. 211. 





Anastomosis forceps. (Laplace). 
18 



274 



MINOR SURGERY. 



by which end-to-end approximation or lateral anastomosis 
can be accomplished with great accuracy and rapidity. 
The forceps are of different sizes, according to the parts 
to be united, and consist of two parts, which are really 
haemostatic forceps curved into a semi-circle on each side 
and held together by means of a clasp; they open as two 
rings. They hold together the parts to be united, and serve 
the same purpose as Senn's bone plates, holding the serous 
surfaces in contact. The sutures are next introduced at all 
points except where the forceps penetrate the parts that are 
sutured. The sutures having been introduced, the forceps 
are released by loosening the clasp, and withdrawing the 
forceps, first one half and then the other half, and the 
small opening is finally closed by one or two sutures. 
These forceps may be used in end-to-end approximation, 
lateral anastomosis, or gastro-euterostomy. 






Ligatures Used in the Treatment of Vascular Growths. 

Various forms of ligatures are used for the strangulation 
of vascular growths; the material used for ligatures is 
usually strong silk or hemp thread, catgut, or silver wire. 
The Single Ligature with a Pin. This is applied by 
first inserting a hare-lip pin through the skin near the edge 
of the growth, passing it under the growth and bringing 

its point out through the 
FlG 212 - skin at a point opposite the 

point of entry ; a strong 
silk or hemp ligature is 
passed under the ends of 
the pin surrounding the 
base of the tumor and is 
drawn tight enough to 
strangulate the growth, and 
is secured by two knots 
(Fig. 212.) If the growth is of considerable size it is 
better before applying this ligature to introduce a second 
pin at right angles to the first one, and then secure the 
ligature under the pins. In applying these forms of liga- 




Vascular tumor strangulated with pin 
and ligature. 



DOUBLE LIGATURE. 



275 



ture to healthy skin the patient is saved much pain, and 
the separation of the mass is hastened, by cutting a groove 
in the skin with a sharp knife at the point where the liga- 
ture is to be applied ; the ligature when tied is buried in 
the groove thus made. 

Double Ligature. This ligature is applied by passing 
a needle or a needle with a handle, armed with a double 

Fig. 213. 




Fig. 214. 



Meiiiud of applying double ligature. (Kob^kts.) 

ligature, through the skin near the growth, and then pass- 
ing it under the tumor and bringing it out through the skin 
at a point directly opposite the 
point of insertion ; the ligature 
is then divided and the needle 
removed. The tumor is strangu- 
lated by tying firmly the corre- 
sponding ends of the ligature on 
each side of the tumor, each liga- 
ture including one-half of the 
growth (Fig. 213). 

The double ligature may also 
be applied by first passing a pin 
under the growth and then pass- 
ing a needle armed with a double 
thread under the tumor at right 
angles to the pin, and after re- 
moving the needle the ends of the 
ligature are tied and the tumor is 
strangulated in two sections (Fig. 
214). 

Quadruple Ligature. In applying this ligature two 
needles carrying a double thread are passed under the 




Method of applying double liga- 
ture and pin. (Bryant.) 



276 



MINOR SURGERY. 



growth at right angles to each other, or if the handled 
needles be used they may be first passed in this manner, 
and then threaded with double ligatures, which are carried 
under the growth as they are withdrawn. The needles 
being removed, the surgeon ties two ends of the ligature 
together, and repeats this procedure until the growth has 
been strangulated in four sections. 

Subcutaneous Ligature. This is applied by introducing 
a needle armed with a ligature through the skin near the 
growth, and carrying it through the subcutaneous tissues 
around the part to be constricted for a short distance, then 
bringing it out through the skin. The needle is again 
introduced through the same puncture, aud is again 

Fig. 215. 




Method of applying subcutaneous ligature. (Holmes.) 



brought out through the skin at some distance from the 
first point of exit. It is next introduced through this 
puncture and brought out at a more distant point. In 
this way the growth is completely encircled by a subcuta- 
neous ligature, which is finally brought out at the point 
of entrance; the tumor is strangulated by firmly tying 
together the ends of the ligature (Fig. 215). 

If a needle armed with a double ligature is first passed 
under the growth the ligature is divided, and by passing 
each end of the divided ligature subcutaneously around 



ERICHSEN'S LIGATURE. 



277 



the growth it may be strangulated subcutaneously in two 
sections. 

Erichsen's Ligature. This ligature is employed to 
strangulate tumors of irregular shape in a number of sec- 
tions. A strong silk or hemp ligature three yards in 

Fig. 216. 




Method of applying Erichsen's ligature. (Erichsen.) 



length, one-half of which is stained black, is carried by a 
needle as a double ligature under the growth at various 
points so as to leave a series of loops about nine inches 
long on each side of the tumor (Fig. 216); the black loops 

Fig. 217. 




Erichsen's ligature applied. 



being cut on one side, the white on the other, the ends are 
then firmly tied so as to strangulate the growth in sections 
(Fig. 217). ' 



278 MINOR SURGERY. 

Elastic Ligatures. Ligatures made of India-rubber 
varying from half a line to several lines in thickness are 
often made use of in surgery. They may be employed to 
strangulate growths such as moles or nsevi, or in the treat- 
ment of fistulae, and are especially useful in the treatment 
of those cases of fistula in ano in which the internal open- 
ing into the bowel is situated high up, as the division of 
such fistulse by this means is accomplished without hemor- 
rhage and with less risk than by the employment of the 
knife. In applying elastic ligatures in such cases the liga- 
ture, after being passed through the fistula by means of a 
probe, is carried out through the internal opening; the 
anus is next well stretched, and the elastic ligature is then 
firmly tied with two or three knots; the greater the ten- 
sion made before the ligature is tied the more rapidly will 
it cut its way out. The smaller sizes of rubber drainage- 
tubes may be substituted for the solid rubber ligatures. 



TREATMENT OF HEMORRHAGE. 

The surgeon may be called upon to treat the following 
varieties of hemorrhage : arterial, venous, or capillary ; 
and these again are classified according to the time of their 
occurrence, as primary — that is, bleeding which occurs at 
the time the wound is inflicted; intermediary or consecutive, 
that which occurs within twenty-four or forty -eight hours 
after the reception of the injury, which generally takes 
place during the period of reaction; and secondary, which 
usually results from a septic condition of the wound and 
takes place after forty-eight hours, and may occur at any 
time subsequent to this period until the wound is healed. 
The treatment of hemorrhage is either constitutional or 
local. 

Constitutional Treatment. This consists in keeping the 
patient in the recumbent posture and avoiding any sudden 
elevation of the head or arms which might induce fatal 
syncope. Opium is a valuable remedy and should be 
freely used. Ergot, gallic acid, acetate of lead, and tine- 



DIGITAL COMPRESSION. 279 

ture of iron may also be employed, and stimulants and 
food should be carefully administered, and in extreme 
cases auto-transfusion or the transfusion of blood or nor- 
mal salt solution may be resorted to. 

Local Treatment. This consists in the adoption of vari- 
ous local measures to control the bleeding, which may be 
either temporary or permanent in their action. 

Temporary Control of Arterial Hemorrhage. 

This may be effected by pressure applied directly to the 
bleeding vessel in the wound or by pressure applied indi- 
rectly to the main artery between the point of its injury 
and the centre of the circulation, and this pressure may 
be made by the fingers, digital compression, by compresses, 
or by means of tourniquets. 

Digital Compression. This constitutes one of the most 
valuable means employed in the temporary control of heni- 

FlG. 218. 




Digital Compression of the femoral artery. 

orrhage; the finger is pressed directly upon the bleeding 
vessel, in the wound, or is used to make pressure upon the 
artery from which the bleeding arises at some point be- 
tween the wound and the centre of the circulation (Fig. 
218). Control of hemorrhage by digital pressure can only 



280 TOURNIQUETS. 

be maintained for a few minutes, for the fingers of the 
surgeon or assistant soon become tired, so that it is only 
employed until means are adopted for the permanent arrest 
of the bleeding. Digital compression of the radial and 
ulnar arteries may be resorted to for the control of hem- 
orrhage during amputations of the fingers, also of the 
axillary and femoral arteries in amputations at the shoul- 
der-joint and the hip-joint. 

It is also used to control hemorrhage from wounds, 
either the result of accident or those made by the knife of 
the surgeon, in which case the finger is placed directly 
upon the divided vessel, or is employed to hold a sponge 
or compress firmly in the wound. 

Compresses. By the use of compresses placed directly 
in the wound or applied to the vessel between the wound 
and the centre of the circulation, the temporary control of 
hemorrhage may be very satisfactorily accomplished. The 
compress which is applied in the wound should be made of 
antiseptic or aseptic gauze, thereby diminishing the chances 
of wound-infection. 

The compress should be held in position by a bandage 
firmly applied, and is generally employed only as a tem- 
porary expedient until a more permanent means of con- 
trolling the bleeding is adopted. 

Tourniquets. These instruments, which are employed 
for the temporary control of hemorrhage from wounds, are 
of many different kinds. 

Petit's Tourniquet. This consists of two metal plates con- 
nected by a strong linen or silk strap, with a buckle — the 
distance between the plates being regulated by a screw 
(Fig. 219). In applying this tourniquet a compress or 
roller-bandage is placed directly over the artery to be com- 
pressed, and may be held in position by a few turns of the 
roller bandage. The lower plate of the tourniquet is 
placed directly over this pad and the strap is tightly 
secured around the limb to keep the instrument in place. 
The screw is then turned so as to separate the plates and 
tighten the strap, thus forcing the compress or pad upon 
the artery and controlling its circulation. This instrument 



TO UBNIQ UETS. 281 

is very generally employed for the control of hemorrhage 
in wounds of the extremities, and is especially useful in 
amputation of these parts, being placed over the main 
artery some distance above the seat of operation. 

Fio. 219. 




Petit's tourniquet. 

The Spanish Windlass. An improvised tourniquet, known 
as the Spanish windlass, may be employed in cases of 
emergency; it is prepared by folding a handkerchief or 
piece of muslin into a cravat and placing a compress or 
smooth pebble on the body of the cravat; this is placed 
over the artery to be controlled, and the ends of the hand- 
kerchief are tied loosely around the limb; a short stick is 
passed through this loop, and by twisting the stick the loop 
is tightened and the compress is forced down upon the 
artery (Fig. 220). 

Many other forms of tourniquet have been devised 
which have the pad and counter-pad arranged to make 
pressure upon the vessel, such as Lister's aorta compres- 



282 



MINOR SURGERY. 



sor (Fig. 221), which is employed in the treatment of aneu- 
rism of the iliac vessels and for the control of hemorrhage 
in amputation at the hip-joint. 
fig. 220 Signorinr's touruiquet (Fig. 222) 

is constructed upon the same prin- 
ciple, and is frequently employed 
to control the circulation in the 
femoral artery in cases of opera- 
tions on the thigh and leg and 




Fig. 221. 




The Spanish windlass. 



Lister's aorta compressor. 



in the treatment of femoral or popliteal aneurism. 

Elastic Constriction. The elastic tube, or strap of Es- 
march's apparatus (Fig. 223) may also be employed for 
the temporary control of arterial hemorrhage, being ap- 
plied above the wound, and if this is not at hand, any 
strong rubber cord, or a piece of large-sized drainage-tube 
may be used as a substitute. In hemorrhage from wounds 
of the hands and feet, especially in children, and in con- 
trolling hemorrhage from wounds of the penis, a piece of 
drainage-tube, firmly applied above the wound, may be 
employed with advantage. Care should be observed in ap- 
plying elastic constriction, for if the elastic tube be applied 
with great force the subcutaneous tissues may be divided 






TOURNIQUETS. 



283 



Fig. 222. 



or nerves may be so compressed that their function is de- 
stroyed. This tube or strap, although generally employed 

to control hemorrhage from ves- 
sels of the extremities, may be 
used to control the femoral artery 
as it crosses the brim of the pel- 
vis, by placing a compress over 
the artery in this position, and 
then applying the elastic band 




Fig. 223. 




Signorini's tourniquet. 



Elastic strap of Esmarch's apparatus 



to secure it with a figure-of-eight turn, passing it under 
the thigh, crossing over the pad, and then carrying the 
ends around the pelvis, and securing them. 

To make pressure on the axillary artery, a compress 
should be placed in the axilla, and the middle of the tube 
placed over this to hold it in position; the ends of the 
tube are then carried over the shoulder where they are 
crossed and then carried to the opposite axilla and secured. 

Haemostatic Forceps. The temporary control of arterial 
hemorrhage by the use of haemostatic forceps is now very 
generally employed in surgical operations, and their use 
has done much to diminish the shock following operations 
from the loss of blood. The haemostatic forceps in gen- 
eral use is self -retaining; it is clamped upon the bleeding 
vessel, and is allowed to remain until the operation is com- 
pleted, when the vessel is secured permanently by the ap- 
plication of a ligature, and the forceps is removed. The 
use of these forceps will be found very satisfactory in con- 



284 



MINOR SURGERY. 



trolling hemorrhage during the removal of tumors, in cases 
of amputation, and for the temporary control of bleeding 

during the operation of tra- 
fig. 224. cheotomy they will be found 

most efficient, as also in ab- 
dominal operations, in which 
their utility was first demon- 
strated (Fig. 224). 

Esmarch's Bandage and 
Tube. This apparatus, which 
is applied to the limbs to 
render them bloodless during 
operations, consists of a rub- 
ber bandage two and a half 
inches in width and three or 
four yards in length, and a 
ill rubber tube two yards in 

length, to one end of which 
is attached a chain and to the 
other a hook, or, better, a 
rubber strap, one inch in 
width and one and a half 
yards in length with a hook 
and chain. The bandage is 
applied to the extremity of 
the limb and is carried up 
the limb to a point some 
distance above the seat of proposed operation ; the ban- 
dage is applied firmly, each turn overlapping one-fourth 
of the preceding one, and when the last turn has been 
made the rubber tube or strap is wound firmly around 
the limb and secured by fastening the hook into oue of the 
links of the chain (Fig. 225). After securing the tube or 
strap the rubber bandage is removed from the limb, and if 
the tube has been firmly enough applied the limb will be 
found to be blanched, and should be free from blood dur- 
ing the operation. Care should be taken not to apply the 
tube or strap too tightly in poorly developed limbs, or on 
parts of the limb where large nerve trunks approach the 




Haemostatic forceps. 



ARTERIAL HEMORRHAGE. 285 

surface, as they may be subjected to an amount of pressure 
which will interfere with their functions subsequently. I 
have knowledge of one case of this nature in which perman- 
ent paralysis of the limb folio wed the use of Esmarch's appa- 
ratus; the tube should be applied with just enough firmness 
to control the circulation. 

Fig. 225 




Esmarch's bandage and tube applied. 



As the strap, when firmly applied, completely cuts off 
the circulation of the parts below, it should be applied for 
as short a time as possible, as gangrene has resulted from 
its prolonged use. 

After the removal of the tube or strap there is generally 
quite free capillary hemorrhage, due to paralysis of the 
vasomotor nerves from pressure, but this in a short time 
stops. This apparatus is of the greatest service in con- 
trolling hemorrhage at the time of operation, and in am- 
putations and removal of vascular tumors from the limbs 
will be found most satisfactory. In operations upon bones, 
such as resection or sequestrotomy, it is especially useful, 
as it allows the surgeon to have a view of the parts unob- 
scured by hemorrhage. I have found its use most satis- 
factory in operations for the removal of foreign bodies, such 
as needles embedded in the hands or feet or extremities. 

Permanent Control of Arterial Hemorrhage. 

To secure this end the surgeon may resort to the use of 
position, cold, heat, styptics, pressure, cauterization, liga- 
tion, torsion, suture of the artery, or acupressure. 



286 MINOR SURGERY. 

Position. In arterial hemorrhage from wounds of the 
extremities elevation of the part will be found to mate- 
rially diminish the amount of bleeding; in hemorrhage 
from wounds of the arteries of the hand, forearm, foot, or 
leg, forcible flexion of the forearm on the arm or of the 
leg on the thigh will be found useful in diminishing the 
force of the blood-current. 

Cold. The application of cold by means of a stream of 
cold water or an ice-bag or pieces of ice will often be 
found an efficient means of controlling hemorrhage from 
vessels of small calibre; it is especially applicable to hem- 
orhage from wounds of the vessels of the mouth, nostrils, 
vagina, or rectum. 

Hot Water. Hot water will be found a very efficient 
means of controlling hemorrhage from small vessels, and 
it may be used in the form of a hot antiseptic solution. It 
is of especial value in capillary or parenchymatous hem- 
orrhage, and is employed in the form of a douche or by 
means of sponges or gauze pads dipped in the hot solution 
and packed into the wound. The injection of hot water 
is a most satisfactory method of controlling uterine hem- 
orrhage. 

Styptics. These agents are sometimes employed to con- 
trol capillary bleeding or hemorrhage from small vessels, 
and although their use is often satisfactory as regards the 
control of the bleeding, they have the disadvantage of 
interfering with the primary union in wounds, and since 
the value of asepsis in wound treatment has been demon- 
strated they are now very seldom employed. The most 
valuable styptics which are used are alcohol, alum, oil of 
turpentine, perchloride of iron, and persulphate of iron or 
Monsel's solution, acetic acid, vinegar, and antipyrin. 

Antipyrin. A solution of antipyrin, 5 per cent., in 
sterilized water possesses marked styptic action. As it 
also possesses antiseptic properties and is not toxic, it may 
be used to control capillary bleeding from the surface of 
the brain, the intestines and peritoneum, and from bone 
cavities. 

Pressure. For the permanent control of arterial hem- 



CA UTERIZA TION. 287 

orrhage pressure may be applied directly to the bleeding- 
point or surface by means of a compress of antiseptic gauze 
or by strips of gauze packed firmly into the cavity from 
whose surface the bleeding arises. 

Compresses are used with the best results where the 
proximity of a bone gives a firm substance upon which 
the vessel may be compressed, as is the case in the vessels 
of the scalp. Pressure applied by means of packing with 
strips of gauze will be found most efficient in controlling 
hemorrhage from cavities such as the nose, vagina, or rec- 
tum, and in the cavities resulting from the removal of 
necrosed or carious bone. Pressure may be indirectly 
applied to an artery by flexing the joint over a compress 
or by firm bandaging of the limb. 

In controlling bleeding from a divided artery in a bony 
cavity, such as the inferior dental, a piece of catgut liga- 
ture may be forced into the canal, and will control the 
bleeding in a most satisfactory manner, or it may be 
controlled by forcing a small piece of Horsley's wax into 
the opening in the bone; this wax is composed of wax, 7 
parts; oil, 2 parts; and carbolic acid, 1 part. 

Halsted has introduced a material known as gut wool, 
which is prepared from the same material from which cat- 
gut is made. This is cut into fine shreds and is used to 
control hemorrhage from bone, being pressed into the 
opening or cavity in the bone from which the bleeding 
arises. 

The troublesome hemorrhage sometimes occurring after 
the removal of a tooth may be controlled by packing the 
alveolar cavity with a strip of iodoform gauze, or by in- 
troducing a wedge-shaped piece of cork and holding it in 
place by fastening the jaws together by means of a bandage. 

Cauterization. The use of cauterization by means of 
a hot iron is a satisfactory method of arresting hemorrhage. 
Care should be taken to have the iron only of a dull-red 
or black heat, as the result desired is not the destruction 
of the tissues, but the coagulating effect of heat upon them. 
The form of cautery iron employed will depend upon the 
size and position of the vessel. Paquelin's cautery is also 



288 MINOR SURGERY. 

a satisfactory apparatus to use for the control of hemor- 
rhage. 

The control of arterial bleeding by cauterization is often 
resorted to in operations upon the jaws and in the removal 
of tumors from the mouth or pharynx or of the tonsils; 
it is also frequently employed to control hemorrhage in 
operations upon the uterus and the rectum, and also that 
resulting from the removal of abdominal tumors, where 
the application of a ligature is difficult and often impos- 
sible. 

Torsion. This method of controlling arterial hemor- 
rhage consists in seizing the end of the artery, drawing it 
slightly out of its sheath and twisting it; it may be accom- 
plished with a single pair of forceps or haemostatic forceps 
or by two pairs of forceps. In the latter method the vessel 
is held by one pair of forceps and is twisted by the second 
pair. 

Torsion of arteries in accidental wounds is quite com- 
mon, and in many cases controls the hemorrhage until sur- 
gical aid is rendered. I have seen the femoral artery in 
Scarpa's triangle completely controlled in this manner in 
a case of avulsion of the thigh from a railway injury. 

In vessels of moderate size it may be practised with one 
pair of forceps, and the ordinary double-spring artery for- 

Fig. 226. 




Double-spring artery forceps. 

ceps (Fig. 226) or haemostatic forceps will be found satis- 
factory for such cases. In larger arteries two forceps 
should be employed, or some of the numerous forms of 
torsion forceps which have been devised for this purpose. 
Ligation. The use of the ligature is by far the most 
generally employed method of controlling arterial hemor- 
rhage. The materials used for ligature are silk, hemp 
thread, or catgut. Catgut or silk is the material generally 
employed. The vessel is seized with a pair of artery or 



LIGATION. 



289 



haemostatic forceps or a tenaculum (Fig. 227) and drawn 
oat of its sheath, and a ligature of sterilized catgut or silk 
is thrown around it and secured by a surgeon's knot, or by 
a reef knot and a surgeon's knot combined, and when 
firmly tied the ends of the ligature are cut short in the 
wound. 



Fig. 227. 




Aneurism needle armed with ligature. 



Fig. 229. 



When ligatures are applied to vessels in their continuity 
they may be threaded into an eyed probe or aneurism 
needle (Fig. 228) and carried 
around the vessel and secured. 

Deep Sutures. A conve- 
nient method of applying a 
ligature to a bleeding point in 
a deep wound, or to a vessel 
in tissues which are of such 
a nature as not to permit of 
the isolation of the vessel, 
is to use a curved needle 
threaded with a catgut liga- 
ture, which is passed deeply 
into the tissues near the vessel and brought out on the 
opposite side; the ligature thus placed is then firmly tied, 
and the ends are cut short in the wound (Fig. 229). 

19 




Artery occluded by suture. (Esmakch.) 



290 



MINOR SURGERY. 



Suture of Arteries. Murphy has practised experi- 
mentally in animals suture of wounded arteries, both in 
longitudinal and transverse wounds. He recommends in 
the larger arteries, where more than two-thirds of the cir- 
cumference has been divided, resection of the injured por- 
tion of the vessel,, where it can be done without removing 
more than three-fourths of an inch of the vessel, and 
invagination of one end into the other, and their fixation 
by fine silk sutures. In longitudinal wounds the edges 
may be brought together by fine silk sutures, introduced 
by means of a fine cambric needle. The sutures should be 
inserted from one-sixteenth to one-twentieth of an inch 
apart, and one-sixteenth of an inch from the edges of the 
wound, and should include only the adventitia and media, 
not perforating the intima. During the operation the cir- 
culation in the vessel should be controlled both above and 
below the wound by forceps covered with rubber tubing. 
Where a distinct sheath is present, it should be sutured 
over the wound, and if this is not present muscle or fascia 
should be sutured over the closed wound in the vessel. 

Acupressure. In this method of controlling arterial 
hemorrhage a needle or pin is used, which is thrust through 
the tissues in such a way as to compress the artery. In 
the first method of acupressure the surgeon places a finger 



Fig. 230. 

I 



Fig. 231. 








Acupressure— first method ; raw 
surface. (Erichsen.) 



Acupressure— first method ; cutaneous 
surface. (Erichsen.) 



of his left hand upon the mouth of the bleeding vessel and 
with his right hand introduces the needle from the cuta- 
neous surface and passes it through the thickness of the 
flap until its point projects for a couple of lines or so from 



ACUPRESSURE. 291 

the surface of the wound a little to the right side of the 
tube of the vessel. By forcibly inclining the head of the 
needle toward his right he brings the projecting portion of 
its point firmly down on the side of the vessel, and after 
seeing that it occludes the artery he makes it re-enter the 
flesh as near as possible to the left side of the wound and 
pushes the needle through the flesh until its point comes 
out again at the cutaneous surface (Figs. 230 and 231). 

There are a number of methods of using the needle or 
pin in acupressure to produce occlusion of the vessel, but 
as this method of arresting hemorrhage is not employed at 
the present time they need not be described. 

Rules for Ligating Wounded Arteries. The follow- 
ing rules for the application of ligatures to wounded arte- 
ries are laid down by Ash hurst : 

1. In cases of primary hemorrhage, no operation should 
be performed upon an artery, unless it is at the moment actu- 
ally bleeding. The exception to this rule is in the cases 
where the vessel is seen to pulsate in the wound or where 
the wound involves the region of a large artery and the 
patient has to be transported or may be in a position not to 
receive surgical aid subsequently if needed; under these 
circumstances, the vessel should be tied or the wound 
should be explored to ascertain the fact that no important 
vessel has been injured. 

2. In applying a ligature to a wounded artery, the sur- 
geon should cut down directly upon it at the point from 
which it bleeds and secure it in the wound. This rule 
holds good for both primary and secondary hemorrhage. 

3. Two ligatures should be applied, one to each end of 
the artery if it be completely divided, and one on each 
side of the wound if the latter has not completely severed 
the coats of the artery. This procedure is adopted for 
the reason that the arterial anastomosis is so free that the 
proximal ligature will not always, even temporarily, arrest 
the bleeding; and if it does accomplish this object at the 
time, after the collateral circulation is established, bleed- 
ing is apt to occur from the distal extremity of the divided 
vessel. If the coats of the artery are not completely sev- 



292 MINOR SURGERY. 

ered their division should be completed, either before or 
after the application of the proximal and distal ligatures, 
thereby favoring the contraction and retraction of the ends 
of the divided vessel. 



Treatment of Venous Hemorrhage. 

Bleeding from small veins often stops spontaneously 
unless there is some pressure upon the wounded veins 
upon the cardiac side of the wound. It is, however, very 
satisfactorily controlled by position or by the application 
of a compress and bandage, or by the use of a ligature; 
if the divided vein be a large one it is well to secure both 
ends by ligatures. The free bleeding arising from rup- 
tured varicose veins of the leg is easily controlled by the 
application of a compress and bandage, while hemorrhage 
from the larger veins, such as the jugular, should be con- 
trolled by the application of ligatures as in the case of 
wounded arteries. 

The Lateral Ligature. The application of the lateral 
ligature to small wounds of veins of large size, such as the 
femoral, or to wounds of venous sinuses, has been recom- 
mended and employed with good results; this procedure 
consists in pinching up the wall of the vein so as to include 
the orifice of the wound and throwing a delicate ligature 
around it. 

Suture of Veins. This procedure has also been em- 
ployed with success in the case of the larger veins. The 
bleeding should be controlled by pressure upon the vein 
upon both sides of the wound, and the wound in the vessel 
should be closed by fine silk sutures applied closely together 
by means of a fine cambric needle. The employment of 
sutures and lateral ligatures in wounds of veins possesses 
the advantage of controlling the bleeding and at the same 
time does not cause obliteration of the vessel at the seat 
of injury. 

Actual cautery may also be employed for the control of 
venous hemorrhage in positions in which its arrest by 
pressure or the ligature is not feasible. 



SECOND AR Y HEMORRHA GE. 293 

Compression by means of strips of sterilized gauze is 
often employed to control venous hemorrhage from cavi- 
ties. 

Treatment of Capillary Hemorrhage. 

Capillary or parenchymatous hemorrhage is usually 
arrested spontaneously by the exposure of the injured sur- 
face of the wound to the air, but it is often so profuse that 
its arrest becomes a matter of importance. To control 
this form of bleeding, pressure may be applied to the bleed- 
ing surface for a short time, and if this fails to arrest it, 
sponging the surface with dilute alcohol will sometimes 
prove satisfactory; but the best application to arrest hem- 
orrhage of this nature is hot water, which may be used in 
the form of a hot bichloride solution or antipyrin solution. 

Acetic acid and vinegar are also sometimes employed 
for the same purpose. In cases where the means men- 
tioned above fail to control the bleeding, it may be neces- 
sary to pack the wound with strips of antiseptic gauze; 
this dressing is most serviceable when the hemorrhage 
comes from the cavities such as result from the removal of 
tumors or excisions of joints, and for the control of bleed- 
ing following the removal of necrosed or carious bone. To 
control hemorrhage from the mucous cavities, such as the 
nose, rectum, and vagina, this method of treatment is fre- 
quently resorted to. 

Treatment of Secondary Hemorrhage. 

Secondary hemorrhage following the use of the ligature 
or other means of controlling bleeding usually results 
from a septic condition of the wound and is due to a 
septic arteritis. Since the adoption of the antiseptic and 
aseptic methods of wound-treatment, it is a much less fre- 
quent complication of wounds. The treatment of this 
complication is both constitutional and local; the constitu- 
tional treatment consists in the use of those remedies which 
were mentioned as serviceable in primary hemorrhage, and 
the drugs upon which the most reliance is to be placed are 
opium and ergot. 



294 MINOR SURGERY. 

The local treatment of this form of hemorrhage consists 
in the use of the various means of eont rolling hemorrhage 
which have been mentioned before, such as the ligature, 
hot water, pressure, or the actual cautery. If possible, it 
is well to secure the vessel from which the bleeding arises 
in the wound; if for any reason this cannot be done, the 
main artery should be ligated above the wound if the 
hemorrhage be arterial. 

Control of Hemorrhage from Special Parts. 

Epistaxis or hemorrhage from the nose may be so pro- 
fuse as to require surgical interference. To control this 
form of hemorrhage the application of iced compresses to 
the surface of the nose may first be made use of, and if 
this fails to control the bleeding, the surgeon or the patient 
should grasp the cartilaginous portion of the nose with his 
thumb and forefinger in such a manner as to keep the nos- 
trils tightly closed, which will prevent the passage of air 
through the nose and thus permit clots to form, arresting 
the flow of blood. Bleeding from the nose often arises 
from the erosion of a small artery low down upon the sep- 
tum; it can be freely exposed by introducing a nasal spec- 
ulum, and the bleeding point can be touched with a cautery- 
iron, avoiding the necessity of plugging the nares. If 
these simple means fail to arrest the bleeding the nasal 
cavity or cavities may be packed with strips of antiseptic 
gauze introduced into the anterior nares, and pushed back- 
ward by a director or probe; this will often be found a 
perfectly satisfactory means of arresting the bleeding. 
This method may be supplemented by a plug of antiseptic 
cotton introduced into the posterior nares with the finger. 
The use of a rubber tampon, consisting of a rubber bag, 
introduced iuto the nares in an empty state and afterward 
inflated, has also been recommended for the control of this 
variety of hemorrhage. 

Another method of controlling hemorrhage from the 
nose consists in introducing a small piece of sponge or 
pledget of sterilized gauze, tied to a strong silk ligature, 



EPISTAXIS. 



295 



into the anterior nares and pushing it back along the floor 
of the nose to the posterior nares; a small piece of sponge 
or gauze about the size of a marble with a hole in the 
centre is threaded on the ligature and pushed back until 
it comes in contact with the first piece introduced, and thus 
by introducing a number of pieces of sponge or gauze in 
this way the nasal cavity may be completely filled up and 
the bleeding arrested. Care should be taken to see that 
the sponge has been rendered aseptic before being intro- 
duced, and the nasal cavity should also be washed out 
with an antiseptic solution before its introduction. The 
sponges or gauze may be allowed to remain in place for 
twenty-four to forty-eight hours (Fig. 232). 

Fig. 232. 




Plugging the nares from the front. (Roberts.) 

Plugging the nares by means of Bellocq's canula is also 
employed to arrest hemorrhage from the nasal cavities; 
the canula armed with a strong ligature, is passed along 



296 



MINOR SURGERY. 



the floor of the nose until it reaches the pharynx, when 
the spring being protruded, the ligature is seized and 
brought out of the mouth and secured to a plug of lint or of 
antiseptic gauze of the required size, and upon withdraw- 
ing the instrument the plug is brought into position in the 
posterior nares and the end of the ligature is allowed to 



Fig. 233. 




Plugging the nares with Bellocq's canula. (Fergtjsson.) 

protrude from the mouth to facilitate its removal (Fig. 
233). An ordinary flexible catheter may be employed in 
place of Bellocq's canula for the introduction of the liga- 
ture. 

Hemorrhage from the Urethra. In hemorrhage from 
the urethra, if profuse, the blood will trickle from the 
meatus, or if efforts at micturition are made the first 
gush of urine will contain blood, but afterward will be 
clear, and the last urine will contain a few drops of pure 
blood. 

This variety of bleeding, if it proceeds from the ante- 
rior portion of the urethra, may be controlled by the intro- 
duction of a catheter and the application of a bandage 



HEMORRHAGE FROM THE RECTUM. 297 

around the penis, carefully applied so as to make only 
moderate pressure. 

If the bleeding comes from the posterior portion of the 
urethra, it will often be controlled by the application of 
cold or pressure to the perineum, or by the introduction of 
a cold steel bougie, or by the injection of a weak solution 
of tannic acid or anti pyrin. 

Hemorrhage from the Bladder. In this variety of 
hemorrhage the first portion of the urine may be blood- 
stained and the last portion will contain more blood and 
clots as the organ contracts, which distinguishes it from 
hemorrhage from the kidneys, in which the admixture of 
blood with the urine renders it of a smoky color or dark- 
red if the bleeding is profuse. 

To control bleeding from the bladder a catheter should 
be introduced and the urine and clots withdrawn; the 
bladder should next be washed out with a warm or cold 
boric-acid solution. In severe cases a weak solution of 
tannic acid, antipyrin or alum may be employed. The 
application of ice to the perineum and supra-pubic regions 
may also be employed with advantage. 

Hemorrhage from the Rectum. This variety of bleed- 
ing may be controlled by the injection of cold or astrin- 
gent enemata. If the bleeding be profuse a speculum 
should be introduced, and when the source of the bleeding 
has been discovered the actual cautery or a ligature should 
be applied. If this is not feasible the rectum may be 
plugged with strips of antiseptic gauze, or a piece of a 
rubber catheter of large calibre may be wrapped with 
gauze and introduced into the rectum, the end of the 
catheter being allowed to protrude; by using this tube 
flatus can escape, and if the bleeding is not controlled 
blood will escape through the tube, preventing the risk of 
concealed hemorrhage. If the bleeding arises from hem- 
orrhoids or polypus of the rectum the operative treatment 
of these conditions should be undertaken to permanently 
control the bleeding. 



298 MINOR SURGERY. 

TREATMENT OF ABSCESS. 

In operations for the evacuation of the contents of 
abscesses care should be taken to observe every precau- 
tion to prevent a new infection of the wound or abscess 
cavity; the skin over the abscess should be carefully 
cleaned to make it aseptic, the hands of the surgeon and 
the instruments to be brought in contact with it should 
also be aseptic. These precautions should be especially 
observed in the opening of chronic abscesses when a new 
variety of infection is liable to be set up if aseptic precau- 
tions are not rigidly observed. 

Acute Abscess. This variety of abscess should be 
opened by incision, and this is best done with a straight, 
narrow, sharp-pointed bistoury; the incision should be 
deep enough to freely expose the cavity of the abscess, and 
should be so planned as to be parallel with and not across 
important structures, and it should also be made at as 
dependent a portion as possible. Abscesses of the limbs 
are opened by a longitudinal incision, and those in the 
region of the anus and breast by an incision radiating 
from the anus or nipple. 

Hilton's Method. In deep-seated abscesses in the region 
of important structures the method of opening suggested 
by Mr. Hilton may be employed with advantage; it con- 
sists in making a small incision through the skin and cell- 
ular tissue; a director is next pushed through the tissues 
into the abscess cavity, which will be shown to have been 
reached by the escape of a little pus along the director; 
a dressing forceps with the blades closed is now pushed 
along the director into the abscess cavity, and when this 
has been accomplished the director is withdrawn and the 
forceps is removed with the blades expanded so as to dilate 
the wound and allow the pus to escape. 

The cavity of the abscess having been emptied of pus, 
it may be irrigated with a stream of carbolic or bichloride 
solution, or the irrigation of the abscess cavity may be 
omitted, and if the cavity is not very large or deep no 
drainage-tube need be introduced, and a small piece of 






TREATMENT OF ABSCESS. 299 

protective may be placed between the lips of the wound 
to prevent their adhesion; but if, on the other hand, the 
cavity is extensive and deeply situated, a rubber drainage- 
tube or a strip of iodoform gauze should be introduced to 
the bottom of the cavity to secure free drainage, and if a 
tube be used, fixed at the surface of the skin by a safety- 
pin. A gauze dressing, consisting of a number of layers, 
which has been moistened in carbolic or bichloride solu- 
tion is next placed over the wound and is covered by a 
number of layers of dry gauze which are in turn covered 
by a piece of rubber tissue. The latter may be substituted 
by a few layers of bichloride cotton, and the dressing is 
finally secured by a roller-bandage. The dressing is re- 
moved at the end of two or three days, the cavity being 
washed out with one of the antiseptic solutions previously 
mentioned. The drainage-tube may then be shortened or 
removed, and the dressings reapplied as at the primary 
dressing. Under this method of treatment acute abscesses 
usually heal promptly. 

Chronic or Tuberculous Abscess. This variety of 
abscess, which occurs chiefly in connection with diseases 
of the bones or joints or of the lymphatic system, is gen- 
erally tubercular in origin, and may be opened in various 
ways, the time at which this should be done depending 
upon the size and situation of the abscess and the amount 
of constitutional and local disturbance which the patient 
experiences from its presence. 

Aspiration. A tuberculous abscess may be evacuated by 
means of the aspirator; the pus being withdrawn as far as 
possible, the puncture is sealed with a small piece of gauze 
covered with iodoform collodion. Reaccumulation of the 
pus often takes place, and the aspiration has to be repeated 
a number of times. The greatest difficulty in the success- 
ful removal of the contents of tuberculous abscesses by 
means of aspiration is the presence of cheesy masses in the 
pus which occlude the canula and ofteu prevent the com- 
plete emptying of the cavity. 

Puncture and Injection. These abscesses may also be 
evacuated by making a puncture through the skin and 



300 TREATMENT OF ABSCESS. 

overlying tissues with a narrow bistoury, the surface 
having been previously thoroughly washed with soap and 
water and with a carbolic or bichloride solution; a direc- 
tor is next pushed through this small wound into the 
cavity of the abscess, and the pus is allowed to escape by 
stretching the wound by the director; when the cavity is 
emptied of pus it is washed out with a carbolic or bichlo- 
ride solution introduced into it by pushing the nozzle of a 
syringe into the cavity, and this is allowed to escape in the 
same way as the pus previously did. When the irrigating 
solution has all escaped the cavity may be injected with 
an emulsion composed of iodoform one part, glycerin ten 
parts; after this has been introduced the small wound is 
closed by a compress of antiseptic gauze held in place by 
a compress of bichloride cotton and a bandage or by strips 
of adhesive plaster. The injection of the iodoform emul- 
sion need not be repeated as long as iodoform continues to 
be excreted with the urine. 

In evacuating tuberculous abscesses by means of the 
aspirator or by a snlall puncture, there is absence of 
shock, and the loss of blood is insignificant, so that these 
procedures should generally be first employed, and the 
more radical operation of incision and curetting of the 
cavity of the abscess, which is accompanied with a certain 
amount of shock and hemorrhage, should be reserved for 
those cases in which the less severe operations have failed 
to be followed by a satisfactory result. 

Incision. Tuberculous abscesses are also treated by 
making a free incision into the abscess cavity with full 
antiseptic precautions, and after the escape of the puru- 
lent matter the walls of the abcess should be thoroughly 
scraped with a curette, and after the cavity has been freely 
washed out with a carbolic or bichloride solution large 
drainage-tubes are introduced and an antiseptic dressing 
is applied to the wound. The edges of the incision may 
be brought together by sutures without the introduction 
of drainage, or the cavity may be packed with iodoform 
gauze and allowed to heal by granulation. The dressings 
are removed as soon as they become soaked, and the drain- 



SHOCK. 301 

age-tubes are shortened or removed as the discharge dimin- 
ishes and the cavity contracts. 

Diffused Suppuration. This form of suppuration is 
treated by numerous punctures or incisions, which allow 
the purulent matter to escape, and where sloughs are pres- 
ent, free incisions may be required to give exit to the 
necrosed tissues; the introduction of drainage-tubes may 
also be required. The wounds and the cavities, as far as 
possible, should be washed out with a carbolic or bichlo- 
ride solution, and an antiseptic gauze dressing should be 
applied. 

Sinuses. There are suppurating tracts which result 
from abscesses or wounds; if superficial, they should be 
laid open freely and their surfaces scraped with a curette 
and then lightly packed with strips of bichloride or iodo- 
form gauze and should be covered by an antiseptic dress- 
ing. If they are too deep to be treated by incision their 
healing may be facilitated by the injection of stimulating 
solutions introduced by means of a syringe; the employ- 
ment of solutions of chloride of zinc, nitrate of silver, and 
sulphate of copper varying in strength from five to twenty 
grains to the ounce of water will often prove satisfactory. 



SHOCK. 

Shock is a condition of physical depression or prostra- 
tion which often develops after severe injuries or opera- 
tions. Shock may develop immediately upon or some time 
after the reception of the injury. Every traumatism is 
probably followed by a certain amount of shock, and, as 
a rule, the degree of shock is proportionate to the severity 
of the injury received. Yet this rule is not without 
exception; certain classes of injuries are attended with 
marked shock, and the part of the body sustaining the 
injury will have an important influence upon the degree 
of development of shock. Contusions of the viscera, 
wounds of the testicle, contused and lacerated wounds of 
the trunk and extremities, if extensive and accompanied 



*x* 



302 MINOR SURGERY. 

by free hemorrhage, are usually followed by marked and 
often fatal shock. Gunshot wounds causing perforation 
of important cavities of the body, injuries of the viscera, 
and shattering of the bones are also wel] recognized as 
giving rise to shock in a marked degree. Burns and 
scalds, if they involve a considerable surface of the body, 
are attended with severe shock. 

A patient suffering from shock presents pallor of the 
surface, paleness of the lips, dilated pupils, clammy moist- 
ure of the skin, muscular debility, occasionally relaxation 
of the sphincters, frequent, feeble, irregular pulse, subnor- 
mal temperature, and feeble, short, sighing respiration; in 
many cases extreme thirst is a prominent symptom. The 
senses are often perfectly retained. The temperature is 
always subnormal, and may vary from a point a little 
below the normal to a point below 90° F. (32° C). A 
depression of temperature below 97° F. (36° C), if it 
persists for a few hours, usually indicates a grave condi- 
tion of shock, and reaction may not occur, although it has 
been observed in cases where the temperature was as low 
as 90° F. (32° C). 

Prophylaxis of Shock. Unfortunately, many of the worst 
cases of shock are due to accidents, and here treatment can 
be directed only to the condition of shock itself, but the 
surgeon is often able to diminish to some extent the amount 
of shock following operations by judicious prophylactic 
treatment. In patients in whom shock is apt to be mark- 
edly developed, as in children or feeble or aged subjects, 
or in certain classes of operations, he may give the patient 
stimulants before the operation, and also see that the sur- 
face of the body is not unnecessarily exposed to chilling 
during the operation, that the operaion is not needlessly 
prolonged, and that as little blood as possible is lost during 
its performance. The electro-thermic mattress may be used 
with advantage. The previous administration of an ounce 
of whiskey and the hypodermic injection of from one- 
twentieth to one-thirtieth of a grain of sulphate of strych- 
nine, and sometimes the use of a small dose of morphine, 
in feeble and aged patients, will often be followed by good 



SHOCK. 303 

results. A full dose of quinine given an hour or two before 
the operation is also said to arrest the development of shock. 

Treatment. The first indication in the treatment of 
shock is to establish reaction. The patient should be cov- 
ered with woollen blankets, the head should be kept low, 
and dry heat should be applied to the surface of the body 
by means of hot- water bags, hot bottles, or hot bricks; 
these should be wrapped in towels to prevent them from 
coming directly in contact with the surface of the patient's 
body; neglect of this precaution, which is most important 
if the patient is unconscious, often produces burns which 
may be followed by extensive sloughing. If the patient 
can swallow, he should be given small quantities of whis- 
key or brandy, with thirty-drop doses of aromatic spirit of 
ammonia, and, as absorption by the stomach is probably 
very slow in these cases, stimulants should be administered 
hypodermically; in our judgment, strychnine is the most 
valuable stimulant that can be employed. From one- 
twentieth to one-thirtieth of a grain should, therefore, be 
injected, and the injection should be repeated every hour or 
half-hour until several doses have been given. Sulphuric 
ether, thirty minims, may also be injected into the cellu- 
lar tissues at intervals, as well as digitalin or tincture of 
digitalis. 

If shock develops during an operation under ether anaes- 
thesia, the use of ether hypodermically is contraindicated. 
A stimulating enema of whiskey and warm water may be 
employed. In cases of shock where there is profuse sweat- 
ing, the use of one-sixtieth of a grain of atropine, repeated 
as required, is often followed by good results. A large 
enema of warm saline solution may also be employed. As 
patients often complain of urgent thirst, it is well to let 
them take a little black coffee, but not large quantities of 
water; free indulgence in water does not seem to quench 
the thirst, and is apt to be followed by vomiting. Intra- 
venous injection of saline solution is likely to be of the 
most service when the condition has been preceded by the 
loss of a large quantity of blood. Infusion of saline solu- 
tion also has been employed with good results. 



304 MINOR SURGERY. 



DRESSING OF WOUNDS. 

Incised Wounds. These wounds present the conditions 
favorable for prompt healing, and they should first be care- 
fully irrigated with a 1 : 2000 bichloride solution, or ster- 
ilized water, to remove any blood-clots or foreign bodies, 
and wiped with a sterilized gauze pledget, and after any 
hemorrhage which is present is controlled by the use of 
ligatures, if the wound be an extensive or deep one, pro- 
vision should be made for drainage by introducing a drain- 
age-tube or a few strands of sterilized catgut at the bottom 
of the wound, allowing the extremity to project from the 
most dependent portion of the wound. In superficial 
incised wounds, after the hemorrhage has been controlled, 
it is not usually found necessary to make any provision 
for drainage. If the wound be a deep one, involving the 
muscles and deep fascia, buried sutures of catgut or silk 
should be applied to approximate the muscles and fascia, 
and if important nerves or tendons have been divided their 
ends should be brought into apposition by sutures of catgut 
or sterilized silk; the superficial portions of the wound 
should next be brought together by the introduction of a 
number of interrupted sutures, catgut, silkworm-gut, silver 
wire or silk being employed for this purpose; the accurate 
apposition of the edges of wounds of this variety is secured 
by the introduction of a number of sutures placed closely 
together. 

After a wound of this variety has been closed the sub- 
sequent dressing is accomplished by covering the surface 
of the wound with a piece of sterilized protective or silver 
foil a little larger than the wound; over this is placed a 
pad of antiseptic gauze, composed of ten or twelve layers, 
which has been soaked in a 1 : 2000 bichloride solution, 
and over this is laid a pad of dry antiseptic gauze of the 
same thickness, overlapping the wet gauze by a few inches 
in all directions; a few layers of bichloride cotton are next 
applied over the gauze dressings, and the whole dressing is 
secured in position by the application of an antiseptic 



LACERATED WOUNDS. 305 

gauze bandage. The protective or silver foil may be 
omitted and the gauze dressing applied directly in contact 
with the wound. Under this form of dressing prompt 
healing of incised wounds is the rule, and the wound need 
not be redressed for a week or ten days unless some indi- 
cations exist for the change of dressing at an earlier 
period. At the time of the first dressing the catgut drain 
or the drainage-tube is usually removed, and if the adhe- 
sion of the edges of the wound is firm the sutures may 
also be removed. An antiseptic or sterilized gauze dress- 
ing is usually next applied and allowed to remain in posi- 
tion for a few days longer. Dry sterilized dressings may 
also be employed. 

Lacerated Wounds. These present edges which are 
torn and not sharply cut, and the vitality of the injured 
parts is often so seriously impaired that prompt union in 
this variety of wounds is not, as a rule, to be looked for. 
Wounds of this nature should first be irrigated with an anti- 
septic solution, 1 : 2000 bichloride solution, and blood-clots 
and foreign bodies should be removed. If the wounds be 
deep, drainage- tubes should be introduced; on the other 
hand, if they be superficial, or if the edges are not closely 
approximated, provision for drainage may be omitted. The 
torn or irregular edges of the wound should next be brought 
into apposition at a few points, by the introduction of catgut 
or silkworm-gut sutures, applied not very closely together; 
and if the edges are discolored and their vitality seems 
markedly impaired, it is better not to use sutures. If the 
edges of the wound are so much crushed as to have their 
vitality destroyed, they may be trimmed away with scis- 
sors until a surface possessing fair vitality is secured. The 
evil results arising from the introduction of sutures into 
this variety of wounds, with the idea of closely approxi- 
mating their edges, are so common that the surgeon who 
dispenses with the use of sutures entirely errs upon the 
safe side. The use of many sutures in wounds of this 
nature often causes marked tension in the wound, which is 
frequently followed by impairment of the vitality of the 
injured tissues, and sloughing results. 

20 



306 MINOR SURGERY. 

The wound should next be dressed antiseptically, and if 
it runs a favorable course it need not be redressed for a 
week or ten days; the time required for the repair of a 
wound of this nature is longer than that for an incised 
wound, and more frequent dressing may be required. 

Iu lacerated wounds of the extremities continuous irri- 
gation of the wound by a warm bichloride or carbolic solu- 
tion, applied as described, is often followed by the most 
satisfactory results; wounds produced by machinery and 
railway accidents, in which the vitality of the tissues is 
much impaired, are particularly favorable cases for this 
method of treatment, and here the same caution should 
be exercised as regards the introduction of sutures. 

Contused Wounds. This variety of wounds possesses 
many characteristics in common with lacerated wounds; 
the edges are bruised and the injury of the subcutaneous 
tissue is often more extensive than the size of the external 
wound would lead one to suspect. They are dressed in 
the same manner as lacerated wounds, and the same objec- 
tion here exists to the use of sutures as in the latter class 
of injuries. 

Punctured Wounds. These wounds are inflicted by 
sharp-pointed instruments, and it often happens that a 
portion of the vulneratiug body remains in the wound, as 
is frequently the case in wounds produced by needles, 
splinters of wood, metal, or glass, and another complica- 
tion in this variety of wound is the injury of vessels, 
giving rise to concealed hemorrhage, or of nerves, result- 
ing in neuritis or neuralgia. Simple punctured wounds 
should be carefully washed with an antiseptic solution and 
covered by an antiseptic gauze dressing, and if no com- 
plication exists their healing is usually very rapid. 

When, however, a foreign body remains in the wound, 
as often happens in punctured wounds produced by 
needles and splinters, the punctured wound should be con- 
verted into an incised wound, and the body should be 
searched for and removed if possible, and in doing this in 
the case of wounds of the extremities the operation is much 
facilitated by the employment of Esmarch's bandage an 



POISONED WOUNDS. 307 

strap. The Rontgen or X-rays may be employed with 
advantage in locating foreign bodies, such as pieces of 
glass or metal, in punctured wounds. After the removal 
of the foreign body the wound is treated as an incised 
wound, and an antiseptic dressing should be applied. 
When concealed hemorrhage occurs after a punctured 
wound, the wound should be laid open and the 'bleeding 
vessel searched for and ligatured if possible, and the wound 
should afterward be dressed as an incised wound. 

Poisoned Wounds. These wounds are caused by the 
absorption, by means of a cut or abrasion in the skin, or 
by the sweat or sebaceous glands, of fluids from a dead 
body in making dissections, or post-mortem examinations, 
or in operating upon living subjects, and often result in 
serious consequences. Infection occurring from a living 
subject in operating is apt to give rise to a similar specific 
infection, or a mixed infection may result, whereas infection 
occurring from dead bodies is usually caused by the bacteria 
of putrefaction, as infective micro-organisms retain their 
virulence for a short time only after death. Such wounds, 
as soon as possible after their reception, should be care- 
fully washed out with a solution of bichloride of mercury, 
1 : 2000, or a 30-grain solution of chloride of zinc, and 
then dressed with an antiseptic dressing. If, however, 
this precaution is not taken, or the wound has escaped 
notice, and in a few hours becomes inflamed and painful, 
and evidences of lymphatic involvement show themselves, 
the wound should be opened and its surface should be 
thoroughly washed out with a 30-grain solution of chloride 
of zinc, and finally with a 1 : 2000 bichloride solution, 
and it should then be dressed with an antiseptic gauze 
dressing. Under this method of dressing the poisoned 
wound is often converted into a healthy one, even 
after the lymphatic involvement is well marked, and it 
usually heals promptly without further constitutional dis- 
turbance. 

Gunshot Wounds. These wounds are produced by 
small shot, or fragments of shells, and are of the nature 
of contused and lacerated wounds, and the vulnerating 



308 MINOR SURGERY. 

body as well as portions of the clothing are often em- 
bedded in the tissues. 

The modern small arms ball has much greater velocity 
than the leaden ball formerly employed; it has great pene- 
trating power, and is more apt to pass through the bones 
without comminuting them. Primary hemorrhage is also 
more common in injuries produced by this ball. Within 
a certain range it also possesses marked explosive action, 
producing great destruction of the tissues with which it 
comes in contact, which has been recently explained upon 
the theory of hydrodynamic pressure or vibratory action. 
In dressing these wounds any foreign bodies, if they can 
be located, should be removed, and in the search for and 
removal of balls from the extremities the applic ation of 
the Esmarch bandage and strap will be found most useful. 
The X-rays may also be satisfactorily employed in locat- 
ing balls or fragments of metal in gunshot wounds. The 
wound should next be thoroughly washed out with a 
1 : 2000 bichloride solution, and an antiseptic dressing 
applied as in the case of other contused and lacerated 
wounds. 

Powder Burns. These result from the explosion of 
powder, and, in addition to the burning and laceration of 
the tissues, are accompanied by the introduction of grains 
of unburnt powder into the skin, which, if not removed, 
leave permanent points of pigmentation. These wounds 
should first be washed with a 1 : 2000 bichloride solution, 
and upon the face, to avoid unsightly pigmentation of 
the skin, care should be taken to pick out the small masses 
of powder with a needle or the sharp point of a tenotomy 
knife. The surface should then be dressed with antiseptic 
gauze or with lint spread with an ointment of boric acid 
or an ointment of aristol, consisting of half a drachm or a 
drachm of aristol to an ounce of vaseline, this dressing 
being covered by a few layers of bichloride or borated 
cotton, held in place by a roller-bandage. 

Contusions or Bruises. These wounds differ from 
contused wounds in the fact that the skin is not broken, 
though in spite of this fact there may exist very extensive 



BUBNS AND SCALDS. 309 

laceration of the subcutaneous tissues, accompanied by 
more or less extravasation of blood from the injured ves- 
sels. "When not severe enough to require operative treat- 
ment they should be dressed by applying over them several 
layers of lint saturated with lead-water and laudanum, 
and over this dressing is placed a layer of waxed paper 
or rubber tissue, aud the dressing is secured by a roller 
bandage. 

A solution which I find most satisfactory in the dress- 
ing of contusions is as follows : Ammonii chloridi, grs. 
xx; tr. opii and alcoholis, aa f5j; aquse, f§j. 

Several layers of lint saturated with this solution are 
laid over the contused tissues, and are covered with waxed 
paper, oiled silk, or rubber tissue. 

Extensive collections of blood following contusions often 
remain in the tissues for some time, but usually are ab- 
sorbed. If this result does not follow, or an abscess forms, 
the blood or pus should be removed by aspiration or by 
incision with full antiseptic precautions. 

Brush-burn. This is a form of contused and lacerated 
wound which is produced by violent friction applied to the 
surface of the body, and is often produced by coming in 
contact with rapidly revolving wheels or the belting of 
machinery, or by the body being rapidly propelled over an 
uneven surface, or by a rope being rapidly drawn through 
the closed hands. The injury may vary from a superficial 
abrasion to the absolute destruction of the skin. The sur- 
face of the brush-burn should be cleansed by a stream of 
sterilized water or 1 : 2000 bichloride solution, and should 
then be dressed with a powder of acetanilid and boric acid, 
equal parts, and a sterilized gauze dressing should be ap- 
plied; if suppuration occurs, a moist bichloride or acetate 
of aluminum dressing or boric ointment should be applied. 

Burns and Scalds. The dressings employed in the 
treatment of burns and scalds are similar, as the injury to 
the tissues is practically the same in both classes of injuries. 
Superficial burns or scalds, in which the effect of the heat 
has only extended to the superficial layer of the skin, may 
be treated by the application of lint saturated with a solu- 



310 MINOR SURGERY. 

tion of carbonate of sodium, a drachm to an ounce of water; 
this dressing rapidly relieves the pain, and is a satisfactory 
application in this variety of burns and scalds. In cases 
in which the effects of heat have extended to the deeper 
tissues, the affected surface may be dressed with carron oil, 
which is prepared by rubbing together lime-water and lin- 
seed oil until a thick creamy paste results; lint is saturated 
with this mixture and laid over the surface of the burn or 
scald. This dressing is a comfortable one to the patient, 
but possesses no antiseptic qualities and soon becomes 
offensive, and for this reason requires frequent renewal. 

The disadvantage met with in the antiseptic method of 
dressing burns and scalds is the fact that the raw surface 
presented offers the most favorable conditions for the ab- 
sorption of the antiseptic substances employed in the dress- 
ings, and for this reason the use of bichloride of mercury, 
carbolic acid, and iodoform is not to be recommended in 
burns or scalds involving a large extent of surface, on 
account of the toxic symptoms which may result from 
their absorption. 

In Germany the treatment of extensive burns by con- 
tinuous immersion of the patient in a hot bath has been 
followed by good results. 

A recent burn or scald, by reason of the heat employed 
in its production, is practically an aseptic wound, and it 
may be dressed by covering it with a number of layers of 
sterilized gauze and cotton, or with powdered boric acid, 
aristol, or acetanilid, and placing over this a number of 
layers of borated or salicylated cotton, and holding the 
dressings in position by a bandage. 

If, however, a full antiseptic dressing is employed, the 
injured surface should first be irrigated with a 1 :4000 
bichloride solution, and then covered with protective or 
rubber-tissue which has been sterilized, and over this a 
dressing of bichloride or sterilized gauze and bichloride 
cotton should be applied. 

When blebs are present upon the surface of the burn or 
scald, they should be opened to allow the serum to escape. 
If suppuration occurs, or the tissues become necrosed by 



INJURIES FROM ELECTRICITY. 31 1 

reason of the severity of the injury, the surface of the 
burn may be washed with a 1 : 4000 bichloride solution, 
and the same dressing should then be applied. 

The ulcers resulting from the separation of the dead 
tissues should be touched with a solution of nitrate of 
silver, four grains to the ounce of water, and dressed with 
lint spread with an ointment of boric acid or aristol. In 
the dressing of extensive burns or scalds of the neck, face, 
and region of the joints, the possibility of serious defor- 
mity from contraction of the tissues in healing should not 
be lost sight of, and position, splints, and bandages should 
be employed to prevent, as far as possible, this complica- 
tion. 

Injuries from Electricity. Since the extensive intro- 
duction of electricity in the arts, injuries from contact with 
heavily charged wires are of frequent occurrence. If the 
current be a strong one, death may be instantaneous, or 
the patient may be knocked down, become unconscious, 
and present severe burns at the point of contact, then 
regain consciousness, and subsequently suffer from numb- 
ness in the extremities, traumatic neuroses, and in rare 
cases true paralysis. If the skin be dry at the time the 
current is received there will be more burning, less pene- 
tration and less shock, and less danger of death. The 
burns are not painful, but are apt to be followed by exten- 
sive sloughing. Alternating currents are more dangerous 
than continuous currents; a continuous current of one thou- 
sand volts is not apt to be followed by serious consequences, 
whereas an alternating current of the same strength is likely 
to produce death. 

Death from exposure to strong alternating currents is 
considered by Hedley to be caused by destruction of the 
tissues or by arrest of respiration producing asphyxia. 
Exposure to a strong electric current may produce burns 
or ecchymoses and occasionally wounds; the latter bleed 
freely and are apt to slough. A burn from electricity pre- 
sents a dry, blackened surface and is surrounded by an 
area of pale skin. They are not as painful as ordinary 
burns, but healing in electric burns is usually slow. In- 



312 MINOE SUEGEBY. 

flamraation and suppuration of the tissue usually develop 
in a few days, and are often followed by the development 
of an extensive area of moist gangrene, a small burn 
being followed by extensive and deep destruction of the 
surrounding tissues. 

The treatment of a person who has been exposed to a 
strong electric current, even if apparently lifeless, consists 
in practising artificial respiration, Laborde's or Silvester's 
method being employed ; also friction to the surface of the 
body and enemataof hot saline solution, and in some cases 
venesection has been employed with advantage. Hedley 
records a case of apparent death in a man who received an 
alternating current of four thousand five hundred volts 
short-circuited through his body for many minutes, who 
showed no signs of life for thirty minutes. In this case, after 
the employment of Laborde's method of artificial respiration 
for some time, normal respiratory action was restored, and 
the patient recovered. Artificial respiration should be 
practised in all cases, and should be continued until it is 
certain that the patient is dead. At the same time strych- 
nine should be used hypodermically. 

The burns should be treated by the application of anti- 
septic dressings, but these often fail to arrest the sloughing. 

DaCosta recommends in the early stage of these burns 
the use of fomentations of hot saline solution, which facili- 
tates the separation of the sloughs, and in the subsequent 
dressing of the wounds, peroxide of hydrogen followed by 
irrigation with saline solution. After the sloughs have 
been separated dry sterilized dressings should be employed. 

Lightning Stroke. In this form of electric injury a per- 
son may be struck directly or may be shocked by an in- 
duced current, the lightning having struck some object 
near at hand. A person struck by lightning may die 
instantaneously or be deprived of consciousness for a 
time, and may suffer from burns superficial or deep. 
Upon regaining consciousness the patient may complain of 
disturbance of vision, and may suffer from paralysis of the 
nerves of motion or sensation; paralysis of the lower limbs 
is said to be more common than that of the upper limbs. 



BEDSORES. 313 

The treatment of the stage of shock following lightning 
stroke consists in the application of external heat, the em- 
ployment of artificial respiration, and the administration 
of stimulants. If burns exist upon the surface of the 
body, they should be treated like burns arising from arti- 
ficial currents. If paralysis persists some time after re- 
covery from the immediate effects of the shock, the use 
of galvanism and the administration of strychnine may be 
followed by good results. 

Bedsores. These sores usually occur over the sacrum 
or hips in patients who are confined to bed for a consider- 
able time, as the result of a long-continued pressure, or in 
those cases where the vital powers are depressed by ady- 
namic diseases, and are also a frequent and troublesome 
complication in spinal injuries, in which cases they result 
from trophic disturbances. Their formation may be pre- 
vented in many cases by the use of air cushions or of a 
water mattress and by keeping the parts exposed to press- 
ure scrupulously clean and frequently bathing them with 
stimulating lotions, such as alcohol, olive oil, and alcohol 
equal parts, or soap liniment. The parts should also be pro- 
tected from pressure by the application of adhesive plaster, 
or, still better, soap plaster spread upon chamois. When 
a bedsore has actually formed, and in many cases its for- 
mation is very rapid and the slough will be found to 
involve a large surface of the skin over the sacrum, and 
to extend down to the bone, we have present a very seri- 
ous complication, and one which requires most careful 
treatment. 

The dressing of a bedsore before the separation of the 
slough consists in relieving the part from pressure by the 
use of an air-cushion placed under the buttocks, and the 
application of a moist antiseptic dressing until the slough 
has separated. AVhen the slough has become detached the 
ulcer remaining should be well irrigated with a 1 : 2000 
bichloride solution, and the granulations should be touched 
with a 5-grain solution of nitrate of silver; and aristol, or 
boric-acid ointment, spread upon lint, should be applied 
to the surface of the ulcer, and a piece of soap plaster a 



314 Minor surgery. 

little larger than the ulcer should be placed over this dress- 
ing, and held in place by broad strips of adhesive plaster. 
This dressing should be renewed every day or every other 
day, and means should be adopted to protect the parts 
from further pressure, and the constitutional condition of 
the patient should be improved by the administration of a 
nutritious diet, tonics, and stimulants. The application 
of the galvanic current has been employed to promote the 
healing of the ulcer in obstinate cases. 

Sprains. Sprains of the joints from twists or other 
external violence resulting in the stretching or laceration of 
the ligaments are injuries which require careful dressing. 

Sprains may be first treated by the application of cold- 
water or hot-water dressings for a few hours, or by the 
application of lead- water and laudanum, the joint being 
kept at rest by the use of a splint or by confining the 
patient in the recumbent posture in the case of sprains of 
the joints of the lower extremities. 

After a few days' use of the lead- water and laudanum 
dressing the swelling usually subsides and the joint may 
be fixed by the application of a moulded soap-plaster splint 
or felt splint held in place by a firmly applied roller-ban- 
dage, which should be worn for a week or ten days; in 
ordinary cases after this time the splint may be removed 
and the patient should be encouraged to use the joint. In 
cases of severe sprains, on the other hand, the pain and 
swelling persist for some time, and here the fixation of the 
joint by a plaster-of-Paris bandage will be found useful 
for a few weeks. 

In the chronic stage of a sprain, after all dressings have 
been removed, the methodical use of massage is often most 
beneficial; and after the parts have been thoroughly man- 
ipulated a flannel bandage should be applied which, by its 
elasticity, gives a certain amount of support to the parts. 

Strapping. The treatment of sprains which I have found 
the most statisfactory, both in the acute and chronic stage, 
consists in the use of strapping. Strips of rubber adhesive 
or adhesive plaster one and a half inches in width are ap- 
plied around the joint, and are made to extend some dis- 



SPRAIN-FRACTURE. 315 

tance above and below it, and a gauze bandage is next 
applied over the straps, and the patient is allowed to use 
the part as soon as he can do so without discomfort (see 
page 167). 

Sprain fracture. Under this name Mr. Callender has 
described an injury which consists in the separation of a 
ligament or tendon from its point of insertion into a bone, 
with the detachment of a thin shell of the bone; this 
injury is apt to occur about the ankle-joint, knee-joint, 
elbow-joint, and wrist-joint, and the treatment is the same 
as that of an ordinary fracture in the same locality. This 
injury is probably much more common than is generally 
supposed in connection with sprains of the joints, and is, 
I think, in many cases the cause of tardy restoration of the 
function of sprained joints, this injury being overlooked 
and the injury simply being treated as a sprain, and the 
patient being encouraged to use the part before the union 
of the bone has been accomplished. 

Strains of Muscles and Fascia. These vary in severity 
from simple stretching of the fibres to absolute rupture 
and should be treated by putting the parts at rest and by 
the application of pressure by means of adhesive straps or 
of a bandage; in strains of the muscles and fascia of the 
back the use of broad strips of adhesive plaster, applied 
as in cases of fracture of the ribs, will be found most satis- 
factory. In the treatment of the latter stages of these 
injuries the employment of massage will often be followed 
by good results. 



PAST III. 

FRACTURES 



In the following article the author has endeavored to 
confine himself simply to a description of the varieties of 
fracture and to their dressing and treatment, and he has 
tried as far as possible to avoid the multiplication of dress- 
ings, being satisfied to describe a few of the methods of 
dressing most frequently employed. He has also avoided 
the description of complicated splints aud dressings, by 
the use of which in certain fractures most excellent results 
are obtained, but has preferred to recommend the employ- 
ment of simple splints and dressings, which can be ob- 
tained by physicians practising in districts remote from 
large cities, where the services of an instrument-maker 
cannot be obtained to construct special apparatus for the 
treatment of these injuries. 

VARIETIES OF FRACTURE. 

Complete Fracture. This is a fracture in which the 
line of separation completely traverses the bone, involving 
the entire thickness of the bone. 

Incomplete Fracture. This is a fracture in which 
there is only a partial separation of the bone-fibres (Fig. 
234), under which name is included partial or "green- 
stick" fracture, in which some of the bone-fibres have 
given way, while the remaining fibres have been bent by 
the force and have not been broken (Fig. 235). Fissured, 



VARIETIES OF FRACTURES. 



317 



punctured, indented, and perforating fractures are also in- 
cluded in the class of incomplete fractures (Fig. 236). 



Fig. 234. 



Fig. 235. 



Fig. 236. 




Incomplete fracture 
of femur. 



Partial or green-stick 
fracture of radius. 



Fissured fracture of the 
humerus. (Gurlt.) 



Simple or Closed Fracture. This is a fracture in 
which there are but two fragments, and the seat of injury 
in the bone does not communicate with the external air by 
a wound in the soft parts. 

Compound or Open Fracture. This is a fracture in 
which the seat of injury in the bones communicates with 
the external air by a wound in the soft parts. 

Comminuted Fracture. This is a fracture in which 
there are more than two fragments, the lines of fracture 
intercommunicating with each other (Fig. 237). 



318 



FRACTURES. 



Multiple Fracture. This is a fracture in which a bone 
is the seat of two or more distinct fractures at different 
points, the lines of fracture not necessarily communicating 
with each other. 

Complicated Fracture. This is a fracture accompanied 
by some serious injury of the parts in the region of the 



Fig. 237. 



Fig. 239. 




Comminuted fracture 
of patella. 





[mpacted fracture. 



Transverse fracture oi 
femur. (Gurlt.) 



fracture — as, for instance, the laceration of important 
bloodvessels or nerves, contusion or laceration of the mus- 
cles, or dislocation of a neighboring joint. 

Impacted Fracture. This is a fracture in which one 
fragment is driven into and fixed in the other, the impac- 
tion taking place at the time of fracture, or being caused 
by a force subsequently applied (Fig. 238). 



VARIETIES OF FRACTURES. 



319 



Transverse Fracture. This is a fracture in which the 
general line of division of the bone is at right angles with 
the long axis of the bone (Fig, 239). Transverse frac- 
tures of the long bones are rarely met with, the line of 
fracture usually being more or less oblique. 

Oblique Fracture. This is a fracture in which the line 
of separation is oblique to the long axis of the bone. This 
is one of the most common directions of the line of frac- 
ture (Fig. 240). 



Fig. 240. 



Fig. 241. 




Oblique fracture of humerus. 
(Stimson.) 



Longitudinal fracture of tibia. 
(Stimson.) 



Longitudinal Fracture. This is a fracture in which 
the line of separation runs in the general direction of the 
long axis of the bone (Fig. 241). This form^of fracture 



320 FRACTURES. 

is rare, but is sometimes met with in the long bones as the 
result of gunshot injury. 

Epiphyseal Fracture or Separation. This occurs be- 
fore complete ossification has taken place between epiphy- 
sis and diaphysis, and is rarely seen after the twentieth 
year of life; the direction of the epiphyseal separation is 
transverse. 

Deformity. The deformity or displacement in fractures 
is either angular, transverse, longitudinal, or rotary. 

Examination of Fractures. In examining a case of 
fracture to locate the nature and seat of the injury, the 
clothing should be removed from the part with as little 
disturbance as possible, and it is better, in most cases, to 
cut or rip the clothing, rather than to attempt to remove 
it in the ordinary manner. The surgeon should first 
inspect the injured part, and, where possible, compare it 
with its fellow, as in the case of injuries of the extremities; 
much valuable information is also derived from the patient 
or his friends as to the manner in which the injury was 
produced. The part should next be carefully examined by 
the surgeon; if it be one of the extremities which is in- 
jured, it should be gently lifted, firm extension being made 
at the same time, the surgeon by his touch and by gentle 
movements seeking to locate the seat of fracture; and he 
may, by his manipulation, at the same time develop crep- 
itus. 

All manipulations should be made with care, and with 
the greatest gentleness, not only to save the patient from 
pain, but also to prevent the soft parts in the region of the 
fracture from being injured by the rough or sharp frag- 
ments of the bone. Rough handling of fractures may 
increase the muscular spasm by the irritation caused by 
the sharp fragments of the bones, and may also result in 
the injury of important vessels and nerves, and indeed a 
simple fracture may readily be converted into a compound 
one by forcible and injudicious manipulations. 

The sooner the examination is made after the fracture 
has occurred the better, for at this time there is less swell- 
ing in the region of the injury, and the surgeon can locate 



PROVISIONAL DRESSINGS OF FRACTURES. 321 

the bony prominences with much more ease, and can often 
discover the exact seat of the fracture with the least 
amount of manipulation of the parts. When a case of 
suspected fracture is not subjected to examination for sev- 
eral days after the reception of the injury, the parts in the 
region of the supposed fracture are often so much swollen 
that it is impossible to accurately locate its seat, and in 
such a case it is often necessary to wait until the swelling 
has subsided before the position of the fracture can be sat- 
isfactorily fixed, the case being treated in the meantime as 
one of fracture. 

Anaesthetics. These may be employed to relieve the 
patient from pain and to obliterate muscular spasm in the 
examination of fractures. Their employment is often of 
the greatest service in the diagnosis of obscure or compli- 
cated fractures, especially those in the neighborhood of 
joints; but the surgeon should remember that all manipu- 
lations should be made with the same gentleness as when 
the examination is conducted without anaesthesia, for there 
is the same risk of injury to the surrounding structures by 
the fragments; this precaution is often neglected when an 
anaesthetic has been given, the surgeon often being inclined 
to handle the parts more roughly than he otherwise would; 
such practice cannot be too severely condemned. 

The use of the fluoroscope or of a skiagraph taken by 
the X-rays has proved a valuable means of locating the 
existence or location of the fracture in obscure cases. 

Provisional Dressings of Fractures. It generally hap- 
pens that fractures occur at localities more or less distant 
from the point where the treatment of the fracture is to be 
conducted, and the transportation of the patient and the 
temporary dressing of the fracture are, therefore, matters 
of the first importance. In fractures of the upper extrem- 
ity, if the fracture be simple, the clothing need not be 
removed, and the arm should be bound to the side by 
some article of clothing, or supported in a sling made from 
handkerchiefs or the clothiDg, aud the patient can usually 
walk or ride for a short distance without much injury to 
the parts in the region of the fracture or inconvenience to 

21 



322 



FRACTURES. 



Fig. 242. 



himself. When the bones of the lower extremities or the 
trunk are the parts involved, the transportation of the 
patient is a matter of more difficulty. When the bones 
of the trunk are involved the part should be surrounded 
by a binder firmly pinned or tied, made from the clothing 
or from towels, or sheets, or other strong materials which 
are at hand. When the bones of the lower extremity are 

involved, if the fracture be a 
simple one the clothing need 
not be removed, and the motion 
of the fragments should be pre- 
vented by applying to the sides 
of the limb, extending above 
and below the seat of fracture, 
strips of wood, shingles, paste- 
board, bundles of straw, strips 
of bark taken from trees, or 
bundles of twigs, these being 
held in place by handkerchiefs 
or strips torn from the clothing 
(Fig. 242). Umbrellas or canes, 
or broomsticks, applied in the 
same manner, may be employed, 
the object of all of these dress- 
ings being to secure temporary 
fixation of the fragments of 
bone during the transportation 
of the patient. 

If the fragments are not fixed 
in some way, but are allowed to 
move about during the trans- 
portation of the patient, much 
damage may result to the soft parts surrounding the frac- 
tured bones, and simple fractures may become compound 
ones by the bones being forced through the skin, the dis- 
comfort of the patient at the same time being much in- 
creased. 

Having applied a dressing to bring about fixation of 
the fragments, the patient should next be placed upon a 




Provisional dressings for fracture of 
the leg. (Esmarch.) 



FRACTURE DRESSINGS. 323 

broad board or settee; if a mattress cannot be obtained, 
the fractured limb should be laid upon a mass of clothing, 
or upon some straw, and he should be placed in a wagon 
or carried to the point where the subsequent treatment of 
the fracture is to be conducted. 

Reduction or Setting of Fractnres. This should be 
effected as soon as possible after the occurrence of the 
injury and as soon as the surgeon is prepared to apply the 
dressings to keep the parts in their proper position; reduc- 
tion at an early period is less painful to the patient and is 
accomplished with more ease to the surgeon than at a later 
period, when marked swelling and inflammation are pres- 
ent at the seat of fracture. Reduction consists in bring- 
ing the fragments, by manipulation, as nearly as possible 
in their normal position, and it is accomplished by exten- 
sion and manipulation with the hands, care being taken to 
use as little force as possible to attain the object. Very 
little force is required if the surgeon places the part in 
such a position as to relax the muscles which produce the 
displacement; when this is accomplished the fragment can 
usually be pressed into position by the fingers without the 
application of any considerable force. When the reduc- 
tion of a fracture has been accomplished the fragments 
are retained in position by the application of various 
splints or dressings which serve to prevent their displace- 
ment. 

Materials and Appliances Used in the Dressing of Fractures. 

The Fracture Bed. Many ingenious forms of beds 
have been devised for the use of patients suffering from 
fractures of the bones of the trunk and lower extremities, 
with the object of permitting the patient to have fecal 
evacuation, without disturbing his position; but a simple 
bedstead provided with a firm hair mattress is usually 
more satisfactory than the complicated form of bed. 

It will be found more convenient in handling the patient 
to use a single bed not over thirty-two or thirty-six inches 
in width, and it is not essential that the mattress be per- 



324 FRACTURES. 

f orated, as a bed-pan can usually be slipped under the 
patient. The use of an ordinary shallow tin pie- plate 
covered with a piece of old muslin to receive the fecal 
evacuations may be substituted for the bed-pan, and will 
be found in many cases more satisfactory, especially in the 
case of children suffering from fracture of the lower ex- 
tremity. 

Splints. After the reduction or setting of the frag- 
ments in cases of fracture they are usually retained in 
position until union occurs by the use of splints held in 
position by means of bandages or strips of muslin. Splints 
may be made of wood, or of tin, lead, copper, or wire, 
binder's board, leather, felt, paper, gutta-percha, or plaster- 
of-Paris. 

Wooden Splints. The simplest and best splints are made 
from wood — white pine, willow, or poplar being the best 
material to employ for their construction, being sufficiently 
strong to give fixation to the parts and at the same time 
being light. Splints made from smooth white pine, wil- 
low, or poplar boards from one- eighth to one-fourth of an 
inch in thickness may be employed in the form of straight 
or angular splints, and their preparation is a matter of 
little difficulty. 

Wooden splints before being applied to the part should 
be well padded with cotton, wool, oakum, or hair, and 
where lateral wooden splints are employed in the treat- 
ment of fractures of the lower extremity it is usual to 
place bandages or junk-bags between the limb and the 
splint. The carved wooden splints which are sold by the 
instrument makers are not to be recommended, as a rule, 
for unless the surgeon has a large number to select from 
it is rare that a splint can be obtained to accurately fit any 
individual case. 

Binder's Board Splints. Binder's board is an excellent 
material from which to construct splints; it is first soaked 
in boiling water, and when sufficiently soft is padded with 
cotton or a layer of lint and moulded to the part. It may 
be secured in position by a bandage; as it becomes dry it 
hardens and retains the shape into which it was moulded. 



FRACTURE DRESSINGS. 325 

Undressed Leather Splints. This is a good material from 
which to construct splints; it is applied by first soaking 
the leather in boiling water, and after padding it with 
cotton or lint it is moulded to the part and retained in 
position by a bandage. 

Felt Splints. These are made from wool saturated with 
gum shellac, pressed into sheets, which is a good material 
from which to construct splints. This material is prepared 
for application to the surface by heating it before a fire 
until it becomes pliable, or by dipping it into boiling 
water. 

Gutta-percha Splints. These are made from sheets of this 
material, in thickness from one-sixteenth to one-fifth of an 
inch, and may often be employed with advantage; they 
are prepared for use by immersing it in hot water, when 
it becomes soft and can be moulded to the surface. Care 
should be taken that it is not allowed to become very soft 
by too long immersion to permit of its being conveniently 
handled. 

Paper Splints. These are made from layers of manilla 
paper stiffened with starch, and constitute a very fair sub- 
stitute for some of the varieties of splints previously men- 
tioned. 

Plaster-of-Paris, Starch, Chalk and Gum, Silicate of Potas- 
sium or Sodium Splints. These may be employed for the 
construction of splints, either movable or immovable, in 
the treatment of fractures; their method of preparation 
and application is described (p. 
99 et seq.); the plaster-of-Paris FlG - 243 - 

dressing is the one which is most 
generally used at the present time. 

Fracture-box. This is a form of 
splint used in the treatment of 
fractures of the lower extremity 
and consists of a piece or board sides. 

eighteen to twenty inches in 

length, with a foot-board firmly secured at its lower ex- 
tremity; the sides are secured by hinges which allow them 
to be raised or lowered (Fig. 243). A fracture-box of 




326 FRACTURES. 

greater length is required for the treatment of fractures 
about the knee-joint. 

Bran, Sand, or Junk Bags. These are constructed by 
taking a piece of unbleached muslin five feet in length 
and fourteen and one-half inches in width, doubling it and 
securing the free margins, except at the mouth, by stitches 
so as to form a bag; the bag is then inverted so that the 
edges of the seams are brought on the inner surface of the 
bag. The bags are next filled with dry sand, bran, or 
hair, or with straw, and the mouth of the bag is closed by 
stitches or by being tied with a string. Bran bags with 
splints, or sand bags are frequently employed in the treat- 
ment of fractures of the femur. 

Bandages. These are made of muslin and are used to 
retain splints in the treatment of fractures, and are also 
sometimes applied directly to the injured part before the 
application of splints to control muscular spasms and limit 
the amount of swelling; when a bandage is so used it is 
known as a primary roller. The use of the primary roller 
is sometimes of the greatest service in the dressing of frac- 
tures, but its use in inexperienced hands has often been 
followed by such unfortunate results in the early treatment 
of fractures, or in cases which are not under constant obser- 
vation, that I think it is a safe rule of practice to discard 
entirely the use of the primary roller. 

Compresses. These are made from a number of folds of 
lint, or of cotton or oakum, and are often employed to 

retain fragments in position or to 
Fig. 244. iii-i v 

make localized pressure upon cer- 
tain points in the treatment of frac- 
tures The compresses are held in 
position by strips of adhesive plas- 
ter, by a few turns of a roller-ban- 
dage, or by the splints. Compresses 
Rack for supporting bed- are sometimes employed to protect 

clothes in fractures of the lower , . / i i i A 

extremity. bony prominences or the skeleton 

from the pressure of the splints, 
but this purpose is often better effected by the use of small 
pieces of soap plaster spread on chamois skin fitted over 
the prominent points. 







MASSAGE IN THE TREATMENT OF FRACTURE. 327 

Rack or Cradle. This is made of wire or wooden hoops, 
and is often employed to support the weight of the bed- 
clothes in the treatment of fractures of the lower extremity 
(Fig. 244). 

Evaporating Lotions in Fracture. The employment 
of evaporating lotions such as lead-water and laudanum, 
or muriate of ammonia and laudanum, to the skin in the 
region of fractures is highly recommended by many sur- 
geons, especially in fractures involving or situated near 
joints. They are here employed to relieve pain, to limit 
inflammatory swelling, and to hasten the absorption of the 
blood and serum at the seat of fracture Many surgeons, 
on the other hand, think that their use causes irritation of 
the skin and delays the process of repair in the union of the 
fracture, and so strongly condemn their employment. Per- 
sonally, I have never seen any bad results arising from 
their use, and have generally employed them in fractures 
near or involving the joints, but I do not consider their 
employment absolutely essential, and when I use them I 
only do so for two or three days. In cases of fractures 
accompanied with much pain and swelling, when the sur- 
geon does not wish to use any of the lotions before named, 
an ointment of ichthyol one part, lanoline three parts, 
spread on lint and wrapped around the limb, will often 
prove a satisfactory dressing, or a layer of cotton may be 
simply wrapped around the part before the application of 
the splints. 

Massage in the Treatment of Fracture. Lucas- 
Champonniere advocates and practises immediate and 
contiuupus massage in the treatment of fractures, and 
holds that by its use pain is diminished, the repair of the 
bone hastened by the profuse deposit of callus, and the 
atrophy of muscles and stiffening of joints avoided. 

Massage is applied as soon as possible after the frac- 
ture has occurred, and consists in manipulations with the 
thumb, the fingers, or the whole hand. The limb is held 
by an assistant and extension is made, or it is placed upon 
a firm pillow or a sand cushion. The manipulations should 
be made in the direction of the muscular fibres and of the 



328 FRACTURES. 

blood-current, and firm pressure should not be made 
directly over the seat of fracture. 

Massage should be practised for from fifteen to twenty 
minutes daily, and no retention apparatus should be ap- 
plied in the intervals unless there is marked tendency to 
displacement of the fragments, when some form of reten- 
tion apparatus or splint may be used. These manipula- 
tions should be continued for some weeks, until union is 
firm at the seat of fracture. Massage has also been com- 
bined with the ambulatory method of treatment of frac- 
tures of the lower extremity. This method of treating 
fractures by massage may be said to be still on trial, suffi- 
cient experience not yet having accumulated to prove that 
it possesses marked advantage over the generally adopted 
method of treatment by immobilization. 

Dressing of Special Fractures. 

Fracture of the Nasal Bones. Fractures of the nasal 
bones are often acompanied with fractures involving the 
septum, the nasal process of the maxillary bone, and the 
nasal spine of the frontal bone. 

The treatment consists is replacing the fragments, if 
displacement exists, by manipulation with the fingers over 
the seat of fracture and by pressure made from within the 
nostrils by a probe or a steel director. When the displace- 
ment is once corrected it is not apt to recur, and in the 
majority of cases no dressing is required. Before resort- 
ing to any manipulation within the nasal cavities the mu- 
cous membrane should be thoroughly cocainized to render 
the operation painless to the patient. When there is a 
return of the depression of the fragments or displacement 
of the septum after correcting the deformity by raising 
the depressed fragment, or bending the septum into place 
by a director, the parts may be held in position by pack- 
ing the nasal cavity firmly with a strip of antiseptic gauze. 

In lateral displacements of the nasal bones from frac- 
ture, after reducing the displacement, a small compress 
held over the fragment by strips of adhesive plaster will 
be the only dressing required. 






FRACTURES OF MALAR BONE AND ZYGOMA. 329 



Mason transfixes the nose, after reduction of the frag- 
ments, with a stout needle, and steadies the pieces with a 
strip of plaster crossing the bridge of the nose and fast- 
ened to the ends of the needle. The needle is kept in 
position for eight or ten days (Fig. 245). Roberts, in 
cases in which there is a displacement of the cartilagin- 
ous portion of the nose, after reducing the deformity, 
holds the parts in position by transfixing them with steel 
pins. 

Fig. 245. 




Mason's dressing for fracture of the nasal bones. 

Profuse hemorrhage sometimes occurs after fracture of 
the nasal bones and may require plugging of the nares to 
control it. 

Fractures of the nasal bones are usually quite firmly 
united in two weeks, and dressings may be dispensed with 
after this time. 

Fractures of the Malar Bone and Zygoma. These 
fractures are usually the result of direct force; the dis- 
placement is upward or backward, and when the zygo- 



330 FRACTURES. 

matic arch is broken the fragments from pressure upon 
the masseter muscle or on the tendon of the temporal 
muscle may interfere with the movements of the lower jaw 
in mastication. This displacement is corrected by cutting 
down upon the fragment and elevating it or by passing a 
tenaculum into the fragment and raising it. 

Outward displacements may be corrected by pressure 
and the application of a compress. The dressing of these 
fractures after the correction of the deformity consists in 
the application of a compress of lint over the seat of frac- 
ture, held in position by strips of adhesive plaster or a 
bandage. There is little tendency to recurrence of the 
deformity after it has been corrected, and union at the 
seat of fracture is usually firm at the end of three weeks. 
Fractures of the Upper Jaw. These fractures may 
involve the body, the nasal processes, or the alveolar pro- 
cesses. The deformity should 
be corrected, and if any teeth 
. ^l i , have been displaced they 

'f mk \ WwUk should be replaced; if there 

is comminution of the alve- 
\ olus the teeth in the separate 

fragments may be fastened 
together by fine wire to fix 
the fragments and hold them 
in place; the teeth of the lower 
jaw should be brought up in 
contact with those of the 
upper jaw, and the jaws 
should be secured together by 
the application of a Barton's 

Dressing for fracture of the upper jaw. K\>\ i /t-c 

or a (jribson s bandage (rig. 
246). Inter-dental splints, made of cork, with grooves to 
fit the teeth, or of gutta-percha, are also employed in the 
dressing of these fractures. The patient should not be 
allowed to move the jaw in mastication, and should be 
nourished by liquid and semi-solid food, which can be 
taken without removing any teeth to give space for its 
introduction. 




v 



FRACTURES OF THE LOWER JAW. 



331 



The bandage should be removed every second or third 
day, and it should be reapplied in the same manner. 

These fractures are usually firmly united at the end of 
four or five weeks, and dressings may be dispensed with 
at this time. 

Fractures of the Lower Jaw. The lower jaw may be 
broken at or near the symphysis, the most usual seat of 
fracture being near the mental foramen; it is often broken 
at two places at once, and the fractures are in many cases 



Fig. 247. 



Fig. 248. 




Dressing for fracture of the lower jaw. 



Four-tailed bandage applied for frac- 
ture of the lower jaw. (Hamilton.) 



rendered compound by laceration of the mucous mem- 
brane, or the injury may consist in a separation of a por- 
tion of the alveolar process of the bone. The dressing of 
a fracture of the lower jaw, after reducing the displace- 
ment and replacing any loosened or detached teeth, con- 
sists in applying a pad of lint under the chin and bringing 
the jaw up against the upper jaw, holding the compress in 
place, and securing the jaws firmly in contact by applying 



332 FRACTURES. 

a Barton's (Fig. 247), modified Barton's or Gibson's ban- 
dage. The bandage should be removed and reapplied at 
the end of the second or third day, and at like intervals 
during the course of treatment. The patient should be 
fed upon a liquid or semi-solid diet, not being allowed to 
chew any solid food until the union at the seat of fracture 
has become firm. 

A very satisfactory temporary dressing for a fracture of 
the lower jaw consists in the application of a four-tailed 
sling (Fig. 248). 

Some surgeons prefer to use an external splint moulded 
from pasteboard or gutta-percha fitted to the chin in the 
dressing of this fracture (Figs. 249 and 250), this being 
padded with cotton and held in place by a Barton's, or 
Gibson's bandage. Where there is much difficulty in 

Fig. 249. Fig. 250. 




Shape of splint before being fitted to chin. Splint moulded to fit 

(Roberts.) chin. (Roberts.) 

keeping the fragments in position the wiring together of 
the teeth may be employed, or the fragments may be per- 
forated with a drill and held in place by a strong silver- 
wire suture; inter-dental splints of metal or gutta-percha are 
also sometimes used for this purpose. During the course 
of the treatment of fracture of the jaws the mouth often 
becomes very offensive from the fermentation of the saliva 
and discharges, and it is well to use frequently a mouth- 
wash of chlorate of potash and tincture of myrrh, or 
boric-acid solution. 

'r The dressings for fracture of the lower jaw are usually 
applied for four or six weeks, the union usually being 
quite firm at the end of this time. 



FRACTURES OF THE RIBS. 333 

Fracture of the Hyoid Bone. In fracture of the 
hyoid bone, if displacement exists, its reduction is facili- 
tated by pressure made with the finger in the pharynx. 

The treatment consists in enforced quiet and the use of 
opium if cough is a prominent symptom, and the inflam- 
matory symptoms may require the employment of active 
local treatment. A dressing may sometimes be employed 
with advantage, consisting of a splint of pasteboard or 
leather moulded to the anterior porton of the neck. 

Fractures of the Larynx or Trachea. In fractures of 
the larynx or trachea where there is little displacement 
and dyspnoea is not marked, the parts should be supported 
by the application of compresses of lint held in place by 
strips of adhesive plaster. If, on the other hand, the 
respiration is embarrassed or there is free expectoration of 
blood, tracheotomy should be performed, and if the injury 
be seated in the larynx the displacement of the fragments 
may be overcome by manipulation with the finger or a 
director through the tracheal wound, or the larynx may 
be packed with a strip of antiseptic gauze to control hem- 
orrhage or hold the fragments in position, the patient in 
the meantime breathing through a tracheotomy-tube se- 
cured in the tracheal wound; the packing should be 
removed in a few days, the tracheotomy-tube being per- 
manently removed as soon as the patient can breathe com- 
fortably through the larynx with the tracheal wound 
closed. In fracture of the trachea the opening into the 
trachea should be below or at the seat of injury. 

Fractures of the Ribs. Fractures of the ribs are more 
frequent than fractures of any other bones of the trunk; 
the ribs most commonly broken are those from the fourth 
to the tenth; the most common seat of fracture is near the 
junction of the costal cartilages or at the angle. The 
dressing of fractures of the ribs is best accomplished by 
enveloping the side of the chest on which the rib or ribs 
are broken with broad straps of adhesive or rubber plas- 
ter. The adhesive straps should be two and a half inches 
in width and long enough to extend from the spine to the 
middle of the sternum. The straps are warmed and the 




334 FRACTURES. 

first strap is firmly applied at the base of the chest, extend- 
ing from the spine to the mid-sternal line; a number of 
ascending straps are applied in this way, each strap over- 
lapping the preceding one by about one-third of its width 
until half the chest is covered in (Fig. 251). This dress- 
ing usually gives the patient much comfort, and the straps 
need not be renewed until they become slightly loosened, 
usually at the end of a week or ten 
fig. 251. days; they should then be renewed 

in the same manner. 

The dressings for fractures of the 
ribs are usually dispensed with at 
the end of three or four weeks, as 
repair of the fracture is generally 
well advanced by this time. 

A satisfactory temporary dressing 
for fractures of the ribs consists in 
surrounding the chest by a broad 

binder of stout linen or muslin; in- 
Adhesive plaster dressing j j c ± 
for fracture of the ribs deed > s ? me surgeons prefer to em- 
(Hamilton.) ploy this dressing during the course 
of treatment, but, as a rule, I think 
it is not as good a dressing as the adhesive plaster dress- 
ing, as the former confines the movements of both sides 
of the chest. 

Fractures of the Costal Cartilages. These fractures 
often take place at the junction of the cartilages with the 
ribs or in the body of the cartilages, and the union of the 
fracture usually takes place by the production of a mass 
of bone at the seat of fracture. The dressing for fractures 
of the costal cartilages consists in the application of strips 
of adhesive plaster applied in the same manner as for frac- 
ture of the ribs, and the dressings should be retained for 
about the same time. 

Fractures of the Sternum. Fractures of the sternum 
are rare injuries, but diastasis of the bones of the sternum 
is a more common accident. The dressing for either variety 
of injury is the same, and consists in the application of a 
compress over the seat of fracture held in place by a broad 



FRACTURES OF THE SACRUM AND COCCYX. 335 



Fig. 252. 




Adhesive plaster dressing for fracture 
of the sternum. 



bandage, or, better, by strips of adhesive plaster (Fig. 
252), applied so as to cover and fix the anterior portion of 
the. chest, covering the entire length of the sternum. This 
dressing should be retained for at least four weeks, being 
renewed if it becomes loose 
at the end of a week or ten 
clays. 

Fractures of the Pelvis. 
These fractures may involve 
the ilium, ischium, pubis, or 
sacrum, and are often seri- 
ous injuries from implica- 
tion of the pelvic viscera. 
The reduction of the dis- 
placement should be first 
accomplished as far as possi- 
ble by external manipula- 
tion, together with internal 
manipulation by the fingers 

introduced into the rectum, or into the vagina in the 
female. The patient should be placed upon a firm bed 
on his back, with the knees slightly flexed over a pillow, 
and the parts should be kept at rest by surrounding the 
pelvis with broad straps of adhesive plaster or a stout 
muslin binder, or by a firmly applied padded pelvic belt. 
The hip-joints should be kept at rest by the application of 
pasteboard splints or by sand-bags. The dressings should 
be retained for a period of at least six weeks. 

When these fractures are complicated by injury of the 
pelvic viscera various operative procedures may be re- 
quired, which will compel the surgeon to modify the 
method of dressing. 

Fractures of the Sacrum and Coccyx. The dressing 
of fractures of the sacrum, after effecting reduction of the 
fragments as far as possible by pressure from within the 
rectum, consists in the application of broad adhesive straps 
around the pelvis, and the patient should be kept at rest 
in bed. 

When the coccyx only is fractured, after reduction of 



336 FRACTURES. 

the displacement, which may sometimes be accomplished 
by manipulation with the finger in the rectum, the patient 
should be confined to bed and the bowels should be kept 
at rest by the use of opium by suppository. The patient 
should be kept at rest for two or three weeks. 

Fractures of the Vertebrae. Fractures of the vertebrae 
are always most serious injuries, not only from the injuries 
of the bones themselves, but also from the damage to the 
spinal cord, membranes, and nerves, which often accom- 
panies them. 

In transporting, or turning in bed, a patient suffering 
from fracture of the vertebrae, great care should be exer- 
cised, for rough or sudden motions might cause a displace- 
ment of the fragments which might, by injury of, or 
pressure upon, the spinal cord, rapidly prove fatal. 

In the treatment of fractures of the spine, if the defor- 
mity is marked, efforts should be made to reduce it by 
extension and counter-extension, and the result may be 
successful, especially if the fracture be associated with a 
dislocation of the vertebrae. In some cases the use of per- 
manent extension by means of weights attached to the 
legs, shoulders, and chest by adhesive plaster and ban- 
dages has been successful in reducing the deformity. 

The patient should be placed upon his back upon a bed 
with a hair mattress, or, better, if it can be obtained, a 
water-bed, which consists of a rubber mattress filled with 
water, which distributes the weight of the patient's body 
evenly over the surface. Whatever form of bed be used, 
the greatest care should be exercised to keep the patient 
absolutely clean, and the parts of the body or limbs which 
are exposed to pressure should be frequently bathed with 
alcohol or soap liniment; and to distribute the pressure, 
small pads should be placed under the parts and changed 
at intervals. These precautions are necessary to prevent, 
if possible, the formation of extensive bedsores, which are 
a frequent and troublesome complication of these injuries. 

The bowels should be carefully watched, and, if consti- 
pation is present, it should be relieved by the use of ene- 
mata; and, as it is not desirable to lift the patient to slip 



FRACTURE OF THE SKULL. 337 

a bed-pan under him, the discharges can be received in a 
flat tin plate pushed under the thighs and buttocks, or on 
pads of oakum or old muslin. 

The care of the bladder is also a matter of the greatest 
importance; the retention which at first exists should be 
relieved by the use of a flexible catheter carefully steril- 
ized and introduced with great gentleness, and when incon- 
tinence supervenes the catheter should also be used at 
intervals; the employment of a soft instrument, if used 
with care, is not apt to produce any injury to the urethra 
or bladder. 

The employment of a plaster-of- Paris jacket has been 
followed, in some cases, by good results, and it may be 
applied early in the case, or it may be used after the 
patient has been kept in the recumbent posture for some 
weeks; by its use it is often possible to get the patient out 
of bed and allow him to sit in a chair. 

In fractures involving the cervictd verterbrce, care should 
be exercised in lifting or moving the head, and it is often 
of advantage in these cases to apply short sand-bags to the 
sides of the neck and head, to give additional fixation to 
the parts while the patient is in the recumbent posture, or, 
if he is allowed to get out of bed, to apply a moulded 
leather or pasteboard splint to the neck, shoulders, and 
back of the head for the same purpose. 

The course of treatment in cases of fractures of the ver- 
tebrae, if the patient does not succumb to the injury in a 
few days or weeks, often extends over many months, and 
recovery is often more or less incomplete as regards the 
function of the parts below the seat of fracture. 

Fracture of the Skull. The treatment of fractures of 
the skull, whether simple or compound, depends largely 
upon the nature of the injury and the condition of the 
cranial contents. In simple fractures unaccompanied with 
cerebral symptoms no special dressing is required, but in 
compound fractures where loose fragments are present, 
these should be removed; and if there is no depression of 
the fragments, and if no cerebral symptoms are present, 
the wound should be drained, carefully closed and dressed 

22 



338 FRACTURES. 

antiseptically, the dressings being held in place by a recur- 
rent bandage of the head. 

The patient should be put to bed, and the use of an ice- 
cap to the head is often of service. The diet should be 
restricted, while calomel and opium or bromide of potas- 
sium should be administered; it is well to keep the patient 
for a few weeks in a quiet and darkened room. Where 
cerebral symptoms are present, either in simple or com- 
pound fractures, and trephining is resorted to, the dressing 
of the wound is similar, and the same general treatment 
should be adopted In all cases of fracture of the skull, 
whether subjected to operative treatment or not, it is well 
to keep the patient at rest in bed for three or four weeks, 
and he should be cautioned to avoid excesses afterward, 
and should not resume active work for some months. 

Fractures of the Clavicle. Fractures of the clavicle 
may be complete or incomplete, and in the latter variety 
of injury the deformity is not usually very marked. The 
indications for treatment in complete fractures of the clav- 
icle are to relax the sterno-cleido-mastoid muscle, to pre- 
vent the weight of the arm on the injured side from 
dragging down the outer fragment of the clavicle, and, by 
fixing the scapula, to carry the attached external frag- 
ment outward and forward. A large variety of dress- 
ings have been devised and used to accomplish these 
objects. 

Dressing by Position. The treatment of fractures of the 
clavicle by position is accomplished by placing the patient 
in bed on his back upon a firm mattress with a low pillow 
under his head, and the arm on the side of injury should 
be fastened to the side of the chest by a few circular turns 
of a bandage passing around the arm and chest; the de- 
formity is usually very satisfactorily reduced upon the 
patient assuming this position, and after three weeks' rest 
in this position the union is generally sufficiently firm to 
allow the patient to get out of bed and be about with the 
arm bound to the side or carried in a sling or with a Yel- 
peau bandage applied, without any recurrence of the 
deformity. 



FRACTURES OF THE CLAVICLE. 



339 



Temporary Dressing. A satisfactory temporary dressing 
for fractures of the clavicle consists in the application of 
a four-tailed bandage; the bandage is made from a piece 
of muslin two yards in length and fourteen inches in 
width; a hole is cut in its centre about four inches from 
its margin, to receive the point of the elbow; the bandage 
is then split into four tails in the line of the hole and to 
within six inches of it; the body of the bandage should 
be applied so that the point of the elbow rests in the hole, 
and a folded towel being placed in the axilla, the lower 
tails should be carried, one anteriorly, the other posteri- 
orly, diagonally across the chest and back, to the neck on 
the side opposite the seat of fracture, and secured; the 



Fig. 253. 



Fig. 254. 





Four-tailed bandage for fracture of Posterior figure-of-eight dressing for frac- 
the clavicle. (Stimson.) ture of the clavicle. (Hamilton.) 



remaining tails are next carried around the lower part of 
the chest and secured so as to fix the arm to the side of 
the body (Fig. 253). 

In some cases the deformity is corrected by the applica- 
tion of a posterior figure-of-eight bandage, the forearm on 
the side of injury being carried in a sling (Fig. 254). 



340 



FRACTURES. 



Sayre's Dressing. This consists of two strips of adhesive 
plaster three and a half inches wide and two yards in 
length. The first strip is looped around the arm just 
below the axillary margin, and is pinned or sewed with 
the loop sufficiently open not to constrict the arm. The 
arm is then drawn downward and backward until the 
clavicular portion of the pectoralis major muscle is put 
sufficiently upon the stretch to overcome the action of the 
sterno-cleido-mastoid muscle, and in this way draws the 
sternal fragment of the clavicle down to its place. The 



Fig. 255. 



Fig. 256. 





Sayre's dressing for fracture of the 
clavicle. First strip applied. 



Sayre's dressing for fracture of the 
clavicle. Second strip applied. 



strip of plaster is then carried completely around the body 
and pinned or stitched to itself on the back (Fig. 255). 
The second strip is next applied, commencing upon the 
front of the shoulder of the sound side; thence it is carried 
over the. top of the shoulder diagonally across the back, 
under the elbow, diagonally across the front of the chest 



FRACTURES OF THE CLAVICLE. 



341 



to the point of starting, where it is secured by pinning or 
sewing. A slit is made in this strip to receive the point 
of the elbow. Before the elbow is secured by the plaster 
it should be pressed well forward and inward (Fig. 256). 

Velpeau's Dressing. This may also be used in the treat- 
ment of fractures of the clavicle (Fig. 258). A compress 
may also be secured by the vertical turns of this bandage 
over the seat of fracture if needed. The application of 
the bandage is described (p. 62). 

In any form of dressing in which the arm is held against 
the side of the chest it is well to apply a folded towel or 
piece of liut between the arm and chest to prevent the 
surfaces from becoming excoriated. 

Modified Velpeau's Dressing. A modified form of Vel- 
peau's dressing for fracture of the clavicle is applied as 
follows : A soft towel or piece of lint is placed against the 
side of the body and over the front of the chest, and held 

Fig. 257. 




Modified Velpeau dressing for fracture of the right clavicle. 

in position by a strip of adhesive plaster; the arm is next 
placed in the Velpeau position, a good-sized pad of lint is 
next applied over the scapula, and this is held in place by 



342 FRACTURES. 

a broad strip of adhesive plaster two and a half inches in 
width and one and a half yards in length; this strip is 
continued downward and forward so as to pass over the 
point of the elbow, and is carried diagonally across the 
chest to the shoulder of the opposite side, and is secured, 
a slit being cut in it to receive the point of the elbow; a 
compress of lint is next placed over the seat of fracture 
and held in place by a strip of adhesive plaster; an addi- 
tional strip of plaster is next carried from the spine around 
the arm and chest and secured on the opposite side of the 
chest; circular turns of a roller bandage are then passed 
around the chest, including the arm from below upward 
until the arm is securely fixed to the body, and the dress- 
ing is finished by making one or two turns of the third 
roller of Desault (Fig. 257). Or the turns of the third 
roller of Desault may be applied first, and the dressing 
may be finished by circular turns of a roller passing around 
the arm and chest, extending from the elbow to the shoul- 
der. 

Fracture of Clavicle in Children. In the treatment of 
fractures of the clavicle in children the Velpeau or modi- 
fied Velpeau dressing will be found to be the most satis- 
factory dressing to employ, and as these patients are 
particularly apt to disarrange their dressings it is well to 
render the dressing additionally secure by applying a few 
broad strips of adhesive plaster over the turns of the 
roller bandage, the strips following the turns of the ban- 
dage. 

The removal of dressings and their reapplication will 
depend upon the comfort of the patient and the manner in 
which they keep their position. As a rule, in fractures of 
the clavicle the dressings are removed at the end of the 
second or third day, the parts are inspected, and the skin 
is sponged off with dilute alcohol; the dressings are then 
reapplied, and if the patient is comfortable and the parts 
are in good position, the dressings are made at less fre- 
quent intervals until union is completed at the seat of 
fracture. 

Union in cases of fracture of the clavicle is generally 



FRACTURES OF THE SCAPULA. 



343 



quite firm at the end of four or five weeks, and at this 
time the dressings may be removed, and the patient should 
carry the arm of the affected side in a sling for several 
weeks, and should not undertake any work requiring 
forcible movements of the arm until eight or ten weeks 
have elapsed from the receipt of the injury. 

The time required for union in fractures of the clavicle 
in children is somewhat shorter; the dressings may be 
removed at the end of three weeks. 

Fractures of the Scapula. Fractures of the scapula 
may involve the body, neck, acromion or coracoid process 
of the bone. Fractures of this bone are quite rare. 

Fracture of the Body of the Scapula. In dressing this 
fracture, if deformity is present, it is reduced by manipu- 
lation, and compresses of lint are placed above and below 
the seat of fracture and held in place by adhesive strips; 
the arm is next fixed to the side of the body by spiral 
turns of a roller bandage passing around the arm and 
chest, and the forearm is supported in a sling. 



Fig. 258. 





Velpeau dressing for fracture of the scapula. 



Fracture of the Neck, Acromion or Coracoid Process of the 
Scapula. These fractures may be dressed by placing a pad 



w** 



344 



FRACTURES. 



Fig. 259. 



of lint or a folded towel in the axilla and binding the arm 
to the body by spiral tarns of a roller bandage passing 
around the arm and chest, and supporting the forearm in 
a sling. Or these fractures of the scapula may be dressed 
by first placing a pad of lint or a folded towel in the axilla 
and then securing the arm in the Velpeau position by the 
application of a Velpeau bandage (Fig. 258). In frac- 
tures of the acromion or coracoid processes the union is 
usually fibrous. In the treatment of fractures of the scap- 
ula the dressing should be retained for about four weeks. 
Fractures of the Humerus. Fractures of the humerus 
may involve the upper extremity, the shaft or the lower 
extremity of the bone 

Fractures of the Upper Extremity of the Humerus. These 
include fractures of the head and anatomical neck of the 
bone, fractures through the tuberosities, 
fractures through the surgical neck of the 
humerus, and epiphyseal fracture or dis- 
junction of the upper epiphysis of the 
humerus. 

The most satisfactory dressing for all 
fractures of the humerus above the upper 
third of the bone is applied as follows : A 
primary roller should be evenly applied 
from the tip of the fingers to the seat of the 
fracture, the arm being flexed at the elbow 
before the bandage is carried above this 
point, to prevent the dangerous constric- 
tion which might result if the bandage were 
applied with the arm in the straight posi- 
tion, and it were afterward flexed at the 
elbow. A folded towel or a thin pad of 
lint should next be placed in the axilla and over the outer 
surface of the chest, to furnish a firm basis of support for 
the humerus and also to prevent excoriation from the con- 
tact of the skin surfaces. A splint of pasteboard, felt, or 
leather (Fig. 259) is next moulded to the shoulder and 
arm; this should be long enough to extend some distance 
below the seat of fracture and wide enough to cover in about 




Moulded splint for 
shoulder and arm. 



FRACTURES OF THE HUMERUS. 



345 



one-half of the circumference of the arm, and is padded 
with cotton and fitted to the shoulder and arm. The splint 
and arm are next secured to the side of the body by spiral 
turns of a roller bandage including the arm and chest in 
its turns and applied from the elbow to the top of the 
shoulder. The forearm is carried in a narrow sling sus- 
pended from the neck (Fig. 260). This dressing should 
be removed at the end of twenty-four or forty-eight hours, 
and after the parts have been inspected and sponged over 



Fig. 260. 




Dressing for fracture of the upper extremity of the humerus. 

with alcohol, the dressings should be reapplied in the same 
manner, and if the patient is comfortable they need not be 
disturbed again for three or four days, subsequent dress- 
ings being made at the same intervals. Union in fractures 
of the upper extremity of the humerus, except in intra- 
capsular fracture, in which bony union is the exception, is 
usually quite firm at the end of five or six weeks, and the 
dressings can be dispensed with at this time. 

Separation of the Upper Epiphysis of the Humerus. This 
accident is not uncommon in patients under eighteen years 
of age, and resembles in many respects fracture of the 



346 



FRACTURES. 



neck of the humerus. There is usually a marked projec- 
tion of the upper extremity of the lower fragment in front 
of the shoulder (Fig. 261). The dressing for separation 
of the upper epiphysis of the humerus is similar to that 



Fig. 261. 




Separation of upper epiphysis of the humerus. 

employed in fracture of the neck of the humerus (Fig. 
260). The functional result following this injury is usually 
very good. 

Fracture of the Shaft of the Humerus. The dressing con- 
sists in the application of a primary roller from the tips 
of the fingers to the seat of fracture; a short, well-padded, 
wooden splint extending from the axilla to a point a little 
above the internal condyle is next placed on the inner sur- 
face of the arm and against the chest; a moulded paste- 
board or felt splint, fitted to the shoulder and outer side of 
the arm and extending a short distance below the seat of 
fracture, is padded with cotton and applied to the shoulder 
and arm. The splints are held in position by the turns of 
a bandage, and the arm is secured to the body by spiral 



FRACTURES OF THE HUMERUS. 



347 



turns of a roller bandage carried around the chest and arm, 
and the forearm is carried in a sling suspended from the 
neck. The dressing is much the same as that for fracture 
of the upper part of the humerus, with the addition of the 
short internal splint. 



Fig. 262. 




Internal angular splints. 

Fracture of the shaft of the humerus may also be dressed 
by first applying a primary roller and then placing the fore- 
arm and arm upon a well-padded internal angular splint 
(Fig. 262). Care should be taken to see that the end of 
the splint extends only to the axilla and does not press 
upon the brachial vein. A pasteboard or felt moulded 
splint is next applied to the shoulder and outer side of the 
arm, which should be long enough to extend below the 
seat of fracture. The splints are held in position by turns 
of a roller bandage beginning at the fingers and carried 
up to the shoulder, and finished with a few spica-of-the- 
shoulder turns (Fig. 263). The arm is supported by a 
sling applied at the wrist, and sometimes for additional 
security the arm is bound to the side of the body by spiral 
turns of a bandage carried around the arm and chest. 
The after-treatment of these fractures as regards the re- 
moval and renewal of the dressings is the same as in cases 
of fracture of the upper portion of the humerus. 

In fractures of the shaft of the humerus the dressings 
should be retained for five or six weeks. 



348 FRACTURES. 

Fracture of the Lower Extremity of the Humerus. These 
include fractures at the base of the condyles, splitting frac- 
tures between the condyles or those of the internal or ex- 
ternal condyle, and epiphyseal fracture or disjunction of the 
lower epiphyis of the humerus. 

Fig. 263. 




Dressing for fracture of the shaft of the humerus with internal angular splint 
and external splint of binder's board. 

In dressing fractures of the lower extremity of the 
humerus, if a primary roller is employed it should be car- 

FlG. 264. 




Anterior angular splint. 



ried up only to the elbow. The displacement is reduced 
by extension and manipulation, and before applying any 



FRACTURES OF THE HUMERUS. 



349 



splint it is well in many cases to apply over the region of 
the fracture several folds of lint saturated with lead-water 
and laudanum, and to cover this dressing with waxed 
paper or rubber-tissue to diminish as far as possible the 
swelling, which is very marked after these injuries. The 
use of this lotion may be omitted, and a layer of cotton 
may be placed around the joint in its place. An anterior 
angular splint (Fig. 264) well padded with cotton or 
oakum is next applied and held in position by the turns 
of a roller bandage applied from the fingers to the upper 

Fig. 265. 




Dressing for fracture of the lower extremity of the humerus with anterior 
angular splint. 

portion of the splint (Fig. 265). These fractures may 
also be dressed with a well -padded internal angular splint, 
this splint being substituted by an anterior angular splint 
at the end of ten days or two weeks. 

Some surgeons prefer to dress fractures of the condyles 
of the humerus with the arm in the extended position upon 
a straight anterior splint, or with short, narrow pasteboard 
splints applied around the joint, as favoring more accurate 
coaptation of the fragments. If this position is employed 
a straight wooden splint is applied to the anterior surface 
of the arm and forearm, or moulded splints of pasteboard 
may be used, and after the union is moderately firm, at the 



350 



FRACTURES. 



end of two weeks, the elbow should be flexed and kept in 
this position during the remaining time of the treatment. 
Treatment by Acute Flexion (Jones's Method). In this 
dressing of fractures of the condyles of the humerus, the 
forearm is placed in a position of acute flexion at the 
elbow, and the hand of the injured arm is brought up and 
is supported by a sling carried around the neck (Fig. 266). 
The flexion of the forearm on the arm may also be secured 
by passing broad strips of adhesive plaster around the arm 

Fig. 266. 




W 



Dressing for fracture of condyles of humerus in acute flexion. 



and forearm. This dressing is applied for three or four 
weeks and then removed and the arm gradually extended. 
It is held that by this method of dressing better motion is 
obtained, and the tendency to gunstock deformity is dimin- 
ished. 

When fractures of the lower extremity of the humerus 
involve the elbow-joint a certain amount of impairment 
of joint-motion is apt to occur either from anchylosis or 



FRACTURE OF THE OLECRANON. 351 

from displacement of the fragments, giving rise to what 
is known as gunstock deformity, which in many cases it is 
impossible to completely reduce, so that flexion and exten- 
sion of the joint are restricted. Bearing these facts in 
mind, it is well to make passive motion in these cases as 
early as the second or third week. It is well to explain 
to the patient or his friends that impairment of joint- 
motion may result in these fractures in spite of the great- 
est skill and care in the treatment. In a case of fracture 
in the regiou of the condyles of the humerus the dressings 
should be removed in twenty-four hours, and it should be 
redressed in the same manner, and if the swelling does 
not increase and the dressing is comfortable to the patient 
it should afterward be dressed at less frequent intervals; 
the union is generally quite firm at the end of four weeks, 
and the splint may be removed at this time. Fractures of 
the condyles of the humerus are very common in children, 
and epiphyseal disjunctions of the lower epiphysis of the 
humerus are also met with; the dressing of these injuries 
in this class of patients is similar to that described for 
fractures of the condyles of the humerus. 

Fracture of the Olecranon Process of the Ulna. 
Fracture of the olecranon may consist in simply a sepa- 
ration of the cortical layer of bone over the summit of the 
process to which the triceps is principally attached, or the 
line of fracture may pass through the sigmoid fossa. 

Fractures of the olecranon are dressed with the arm 
slightly flexed at the elbow, or with it completely extended; 
the former position is possibly a little less irksome to the 
patient. The separation of the fragment by the action of 
the triceps muscle is usually not very marked; but, if the 
displacement is considerable, it may in a measure be over- 
come by the use of a compress above the fragment, over 
which figure-of-eight strips of adhesive plaster are fastened 
to draw it down into position (Fig. 267). The ends of the 
strip are then attached to a well-padded straight splint 
which should be long enough to extend from the upper 
third of the arm to the ends of the fingers, which is secured 
in position by the turns of a roller carried from the fingers 



352 



FRACTURES. 



to the upper extremity of the splint, with figure-of-eight 
turns at the elbow to reinforce the action of the strips of 
plaster (Fig. 268). 



Fig. 267. 




Adhesive strap applied to draw fragment downward. 

This fracture may also be dressed by first applying a 
primary roller up to the elbow, and then placing the arm 
upon a well-padded anterior obtuse-angled splint, or a 
straight splint with a good-sized pad of lint or oakum 

Fig. 268. 




Fracture of olecranon dressed in the extended position. 

fastened at a point corresponding to the position of the 
flexure of the elbow. When either of these splints is 
placed upon the arm a position of moderate flexion is 
obtained. A compress of lint is next placed above the 
fragment, if there is a displacement, and one or two nar- 
row strips of adhesive plaster are fastened over this and 
passed obliquely downward and attached to the splint on 






FRACTURES OF HEAD AND NECK OF RADIUS. 353 

either side. The splint is then securely fastened to the 
arm by the turns of a roller bandage applied from the 
fingers to the upper end of the splint. 

The dressings in a case of fracture of the olecranon 
should be removed at the end of twenty-four or thirty-six 
hours, or sooner if there is evidence of swelling of the 
tissues in the region of the fracture, and they should be 
reapplied in the same manner. If the dressing is com- 
fortable to the patient, and there is no evidence of swell- 
ing, the subsequent dressings should be made at less fre- 
quent intervals; the dressings are usually retained in this 
fracture for five or six weeks. Passive motion should not 
be made until this time, as flexion of the elbow tends to 
separate the fragments, unless union has taken place. 
The union of a fracture of the olecranon is, in most cases 
fibrous, but in a few instances bony union has been 
observed. 

Fracture of the Ooronoid Process of the Ulna. Frac- 
ture of the coronoid process is rarely met with, and its 
dressing is accomplished by placing the arm in a flexed 
position and applying a well-padded internal right-angled 
splint, or a posterior right-angled splint, and securing it 
to the arm by the turns of a roller-bandage. A moulded 
pasteboard or leather gutter may be substituted for the 
angular splint. The dressings should be changed at inter- 
vals, and after their removal, at the end of three or four 
weeks, passive motion should be practised. 

Fractures of the Head and Neck of the Radius. 
These fractures are also quite rare, and, when met with, 
should be dressed, after reducing the fragments by manip- 
ulation, by flexing the elbow and keeping it in this posi- 
tion by the application of a well-padded anterior right- 
angled splint, the splint being firmly secured in position by 
the turns of a roller bandage applied from the tips of the 
fingers to the upper end of the splint (Fig. 265). The splint 
should be changed at intervals, and should not be perma- 
nently removed for four weeks, at which time passive 
motion, consisting in flexion and extension at the elbow and 
pronation and supination of the forearm, should be made. 

23 



354 FRACTURES. 

An internal angular splint applied to the inner surface 
of the forearm and arm may also be used in the treatment 
of these fractures (Fig. 262). 

Fractures of Both Bones of the Forearm. These 
fractures are often met with as the result of direct or indi- 
rect violence, and after reducing the displacement, which 
is always marked when both bones are broken, and is not 
so marked when one bone only is broken, by making 
extension from the hand and by manipulation, the fore- 
arm is placed in the supine position or in a position be- 
tween pronation and supination. The supine position is, 
as a rule, to be preferred in any fracture of the radius, as 
the upper fragment is supinated by the action of the biceps 
and supinator brevis muscles, and, therefore, unless the 
lower fragment be placed in the supine position, union 
with rotary deformity will almost inevitably ensue. 

Two straight wooden splints, well padded, a little wider 
than the forearm, are employed. The anterior splint 

Fig. 269. 




Dressing for fracture of both bones of the forearm. 

should be long enough to extend from the elbow to the 
tips of the fingers, and the posterior splint should extend 
from the elbow to the wrist. A primary roller should 
never be applied to the forearm in dressing these frac- 
tures, as its application diminishes the interosseous space, 
and its use has been followed by gangrene of the hand and 
forearm. In applying the anterior splint to the palmar 



FRACTURES OF BOTH BONES OF FOREARM. 355 

surface of the forearm and hand, care should be taken to 
see that the upper end of the splint does not press upon 
the brachial artery and basilic vein at the elbow when the 
forearm is flexed; the posterior splint is next applied from 
the elbow to the wrist, and the splints are held in position 
by the turns of a bandage carried from the fingers to the 
elbow (Fig. 269). 

In dressing this fracture a posterior splint equal in 
length to the anterior splint may be used in place of the 
short posterior splint extending from the elbow to the 
wrist. 

In fracture either of the shaft of the radius or of the 
ulna alone, the deformity is usually not so marked as 
when both bones are broken at the same time, the un- 
broken bone acting as a splint; the dressing for these frac- 
tures is the same as for fracture of both bones of the 
forearm. 

The dressing should be removed in twenty-four or 
thirty-six hours, and after inspecting the parts and spong- 
ing them with dilute alcohol the splints should be replaced 
in the same manner and secured. The dressiugs should 
be removed and renewed at intervals of two or three days 
for two weeks at least, and after this time the dressings 
should be made at less frequent intervals. The time 
required for union in these fractures is usually five 
or six weeks, and the splints should be retained for this 
time. 

In children incomplete or green-stick fractures of the bones 
of the forearm are very common : their dressing, after re- 
ducing the deformity, which consists in bending the bones 
back into place, often converting the incomplete fracture 
into a complete one, is accomplished in the same manner 
as described above. In these patients there is a great ten- 
dency to displace the splints or rather to draw the forearm 
out of the splints, and to prevent this I often employ an 
anterior angular splint, in place of the straight anterior 
one, the upper portion of which, being fastened to the 
arm, prevents the child from dragging the arm out of the 
dressings. 



356 



FRACTURES. 



Fracture of the Lower End of the Radius. The most 
common fracture of the radius is one situated from one- 
half of an inch to one and one-half inches above the lower 
articular surface of the bone (Colles's fracture), the line of 
fracture being more or less transverse, although it may in 
some cases be slightly oblique; the characteristic deformity 
in this fracture is represented in Fig. 270. 

Fig. 270. 




Fracture of the radius near its lower extremity. 

The most important point in the treatment of this frac- 
ture is to effect complete reduction before the application of 
any splint; this is done by making extension from the hand, 
and, at the same time, by over-extending and then flexing 
the wrist and by manipulation, the deformity can usually 
be completely reduced. The arm should then be brought 

Fig. 271. 



/ 









Position oi compress in Colles's fracture. 



into the position of supination, and a firm compress of 
lint is next placed over the lower end of the upper frag- 
ment on the palmar surface of the forearm; a second 
compress is then placed over the upper end of the lower 



FRACTURE OF LOWER END OF THE RADIUS. 357 

fragment (Fig. 271), and a well-padded Bond's splint (Fig. 
272) is applied to the palmar surface of the arm and held 
in place by the turns of a roller bandage (Fig. 273). 

Many surgeons treat this fracture with the hand in a 
position between pronation and supination, the thumb 
pointing upward. A substitute for Bond's splint may be 

Fig. 272. 




W 



Bond's splint. 



Fig. 273. 



t?#*H 



Dressing for fracture of the lower end of the radius. 
Fig. 274. 




Substitute for Bond's splint. 



prepared by fastening a roller bandage obliquely upon a 
straight wooden splint as suggested by Dr. Hays (Fig. 
274). 



358 FRACTURES. 

Another method of treating Colles's fracture after the 
reduction of deformity consists in placing upon the dorsal 
surface of the forearm a padded straight splint, extending 
from the elbow to the tips of the fingers, and a short, straight 
splint upon the palmar surface of the arm, extending from 
the elbow to the wrist. These splints are held in position 
by a bandage, and the forearm carried in a sling with the 
hand inclined to the ulnar side (Fig. 275). The hand 
should be bandaged to the posterior splint for about seven 
days and then set free. The posterior splint should be left 

Fig. 275. 




if 



Dressing for Colles's fracture with long posterior and short anterior splint. 

long for another week; at the end of this time it should 
be shortened so as to extend only to the wrist-joint, and 
the patient should be encouraged to use the fingers and 
make motions of the wrist. At the end of three weeks 
both splints should be removed, and the patient should 
carry the forearm in a sling for a few weeks longer and be 
encouraged to use the hand. 

The most important point in the treatment of this frac- 
ture is the complete reduction of the deformity at the first 
dressing, and if this has been satisfactorily done almost 
any splint may be used with a good result, and, indeed, 
some surgeons use no splint, applying only a compress 
over the seat of fracture, held in place by a strip of 
plaster, the arm being carried in a sling. 

The after-treatment of these fractures consists in remov- 
ing the splint and compresses after twenty-four or thirty- 
six hours and in sponging the surface of the skin with 



FRACTURES OF THE METACARPAL BONES. 359 

dilute alcohol, and the compresses and splint should then 
be reapplied in the same manner; the fracture should be 
dressed every second or third day for the first two weeks, 
and after this time it should be dressed at less frequent 
intervals. Union is usually quite firm at the eud of four 
weeks, and the splint should be dispensed with at this 
time. A certain amount of stiffness of the wrist and fingers 
is apt to follow this fracture, which is usually soon over- 
come by passive motion and physiological use of the parts. 

In children epiphyseal separations or fractures of the 
lower epiphysis of the radius are often met with, and their 
treatment is similar to that described above; a Bond splint 
with compresses or two straight splints with compresses 
being the most satisfactory dressing to employ in this 
injury, the dressings being retained for three weeks. 

Fractures of the Carpal Bones. These fractures are 
usually compound or open fractures, and are so frequently 
associated with extensive laceration of the arm and hand 
that operative measures have to be resorted to; but if such 
is not the case they are dressed, when compound, with an 
antiseptic dressing, and the hand and forearm are supported 
upon a well-padded palmar splint held in place by a roller 
bandage; more or less impairment in the motion of the 
wrist is apt to follow these fractures. The dressings should 
be retained for three or four weeks, and after their removal 
passive motion should be employed to overcome as far as 
possible the joint-stiffness resulting. 

Fractures of the Metacarpal Bones. These fractures 
are often met with as the result of direct or indirect force 

Fig. 276. 




Agnew's splint for fracture of the metacarpal bones. 

applied to the metacarpal bones. The treatment of frac- 
tures of the metacarpal bones consists in first reducing the 
deformity, which is usually an angular one, the projection 



360 



FRACTURES. 



of the angle being toward the back of the hand; this is 
reduced by pressure with the fingers, and the hand and 
forearm should then be placed upon a palmar splint (Fig. 
276) with a pad of oakum or cotton under the palm; a 
compress of lint is next placed over the seat of fracture, 
and the hand and forearm are bound to the splint by the 



Fig. 277 



/ 




I 



Dressing for fracture of the metacarpal bones. 



turns of a roller bandage (Fig. 277). At the end of three 
weeks union at the seat of fracture is usually quite firm, 
and the splint should be dispensed with at this time. 

Fractures of the Phalanges. The treatment of frac- 
tures of the phalanges consists in reducing the displace- 
ment by extension and manipulation, and in placing the 

Fig. 278. 







Gutta-percha splint for fracture of phalanx. (Hamilton.) 

finger in a moulded gutta-percha or pasteboard splint (Fig. 
278), and securing the splint in position by the turns of a 
roller bandage. When the proximal phalanx is fractured 
a narrow, padded, wooden splint extending from the end 



FRACTURES OF THE FEMUR. 361 

of the finger to the wrist should be applied upon the pal- 
mar surface of the finger and hand, and a short dorsal 
splint should also be used; if there is a tendency to lateral 
displacement short lateral splints should also be employed, 
and the splints should be held in place by strips of plaster 
or by a roller bandage (Fig. 279). 




^ 



Dressing for racture ot phalanx with anterior and posterior splints. 

Union in fractures of the phalanges is usually quite firm 
at the end of three weeks, and the splints can be dispensed 
with at that time. 

Fractures of the Femur. These may involve the neck, 
great trochanter, and upper end of the shaft, the shaft, or 
the lower extremity of the bone. 

Fractures of the Upper Extremity of the Femur. In dress- 
ing these fractures the patient should be placed in bed upon 
a firm mattress, and an extension apparatus made from 
adhesive plaster should be applied to the leg, extending as 
far as the knee-joint. The extension apparatus is con- 
structed by taking a piece of adhesive plaster two and a 
half inches in width and long enough to extend from the 
outer side of the knee to four inches below the sole of the 
foot, and from this point back to the inner side of the knee; 
in the centre of this strip is placed a block of wood, two 
and a half inches wide and four inches in length, with a 
perforation in its centre; the block and the inner surface 
of the strip on each side are next faced with a similar strip 
of adhesive plaster to a point about an inch above each 
malleolus; a few straps are next wound around the wooden 



362 



FRACTURES. 



block to fix the previously applied straps; the strip of plas- 
ter is next warmed and applied to the sides of the leg and 
held in position by three strips of adhesive plaster carried 
around the leg at intervals (Figs. 280), and the plaster is 
made additionally secure by the application of a roller 
bandage applied to the foot and leg and carried up to the 
knee. 

Through the perforation in the block or stirrup is fast- 
ened a cord which passes over a pulley attached to the 
bed, and to this cord is attached the extending weight. 
The extension apparatus being applied, lateral support is 
given to the leg and thigh by sand-bags applied on either 
side; the outer sand-bag should extend from the foot to 



Fig. 280. 




Adhesive plaster extension apparatus applied to limb. (Ashhcrst.) 

the axilla, and the inner one from the foot to the groin. 
A weight of five or ten pounds is attached to the extend- 
ing cord, and the lower feet of the bed should be raised on 
blocks a few inches high to prevent the patient from slip- 
ping down in bed; a pad of oakum or cotton should also 
be placed under the tendo-Achillis to relieve the heel from 
pressure. This dressing is kept in place for from four to 
six weeks, and if union has occurred the patient is kept 
in bed for a few weeks longer and is then allowed to be 
about, using crutches. In the majority of cases of frac- 
ture of the neck of the femur fibrous union only takes 
place, and after employing the dressing before described 



FRACTURES OF THE FEMUR. 363 

for six weeks the patient is allowed to get up and go about 
on crutches. It often happens that the subjects in whom 
these fractures occur are old and feeble, and if it is found 
that restraint in bed with the dressings here described is 
not well borne, under such circumstances they should be 
discarded and the patient should be allowed to sit up in 
bed with the limb resting on a pillow, or to get into a 
chair, the treatment of the local condition having to be 
disregarded, attention being given to the patient's con- 
stitutional condition. 

In fractures of the neck of the femur and of the upper 
part of the shaft of the bone the anterior wire splint of 

Fig. 281. 




Smith's anterior splint for fracture of the femur. 

Prof. N. P. Smith is sometimes used with advantage; the 
limb being swung from the splint the patient is able to 
move in bed without causing him pain or disturbing the 
fragments (Fig. 281). In fractures in the upper portion 
of the femur where there is marked tilting forward of the 
upper fragment Prof. Agnew employed extension made 
from the thigh and placed the limb upon a double inclined 
plane, maintaining this position during the treatment of 
the case (Fig. 282). With the same object in view, in 
place of the double inclined plane a double inclined frac- 



364 



FRACTURES. 



ture-box may be employed (Fig. 283), extension being 
made from the thigh by means of adhesive plaster strips 
applied above the knee, to which a weight is attached. 



Fig. 282. 




Dressing for fracture of the femur with extension upon an inclined plane. 
(Agnew.) 

Fracture of the Shaft of the Femur. In the treatment of 
fractures of the shaft of the femur the dressings are ap- 
plied to diminish as far as possible the shortening and to 
prevent angular or rotary displacement of the fragments. 
In dressing these fractures the patient should be placed 

Fig. 283. 




Double inclined fracture- box. 



upon a fracture-bed or an ordinary bed with a firm hair 
mattress; an extension apparatus of adhesive plaster is 
applied and extension is made by a weight attached to this 
as previously described. Lateral support is given to the 
limb by the application of two wooden splints — the outer 



FRACTURES OF THE FEMUR. 



365 



or long one extending from the axilla to the foot, the inner 
or short one extending from the groin to the foot. The 
splints at their upper extremity should be about six inches 
in width and at their lower extremity about three and a 
half inches. The splints are wrapped in a splint cloth 
which extends from the foot to the groin, and after this 
has been placed under the limb the splints are fixed in 
their proper positions, the short one to the inner side, the 
long one to the outer side of the limb. Between the limb 
and the splints are interposed bran-bags : the outer bag 
should be long enough to extend from the axilla to the 
foot, the inner one from the groin to the foot. The splints 
and bran-bags are held in place by five or six strips of 
bandage passing under the limb and body and around the 
splints and bran-bags at intervals. The heel is saved from 
pressure by placing a wad of oakum or cotton under the 
tendo-Achillis, and after the splints have been brought 
into place the strips of bandage are firmly tied to secure 
them, and a weight of ten or twelve pounds is attached to 
the extending cord. The foot of the bed is raised to pre- 
vent the patient from slipping downward and to allow the 



Fig. 284. 




Dressing for fracture of the shaft of the femur with lateral splints and bran-bags. 

(ASHHURST.) 



weight of the body to act as a counter-extending force. 
After the application of the dressings the thigh should be 
slightly abducted. During the after treatment of these 



366 FRACTURES. 

fractures the surgeon should see that the splints and bran- 
bags are kept firmly in place and that the foot does not 
roll outward; this is accomplished by untying the strips 
and readjusting the bags and then bringing up the splints 
and securing them in position by fastening the strips (Fig. 
284). The extension apparatus usually does not require 
renewal during the course of treatment. The extension 
apparatus and splints are kept in place for four or six 
weeks, and at this time union at the seat of fracture is 
usually quite firm, so that they may be removed, and the 
fracture is then supported by moulded pasteboard splints 
or by the application of a plaster-of-Paris splint for several 
weeks longer, and at the end of eight weeks it is safe to 
allow the patient to be up and around on crutches. 

Many surgeons, in fracture of the shaft of the femur, 
prefer to use a long external sand-bag and a shorter inter- 
nal one in place of the corresponding long and short splints 
and bran-bags, and if care is observed to see that the sand- 
bags are kept accurately in contact with the limb and 
body, excellent results may be obtained by this form of 
dressing. After considerable experience with both meth- 
ods of furnishing lateral support in the dressing of frac- 
tures of the shaft of the femur, I am well satisfied that 
angular deformity is less likely to result where the splints 
and bran-bags are employed. 

The plaster-of-Paris dressing, including the foot, leg, 
thigh, and pelvis, is employed by some surgeons in the 
early treatment of fracture of the shaft of the femur, the 
limb being kept well extended until the plaster has thor- 
oughly set. In applying this dressing the patient should 
be placed upon the pelvic supporter (see p. 94). 

Fracture of the Lower End of the Femur. The fractures 
met with in this portion of the femur are supra-condyloid 
fractures, those in which one condyle is separated from 
the other, or comminuted fractures in which both condyles 
are separated; epiphyseal disjunctions of the lower end of 
the femur, met with in young subjects, may also be classed 
with fractures at this portion of the bone. 

The dressing of supra-condyloid fractures, if there is 



FRACTURES OF THE FEMUR. 367 

shortening, should be similar to that employed in fractures 
of the shaft of the femur, consisting in the application of 
an extension apparatus and bran-bags and splints or sand- 
bags to give lateral support ; if, however, there is no 
marked shortening the dressing employed should be the 
same as that applied in fractures involving one or both 
condyles or epiphyseal separations. 

The dressing employed in fracture of one or both con- 
dyles or in epiphyseal disjunction of the lower end of the 
femur consists in placing the limb in a long fracture-box 
extending from the foot to the upper third of the thigh, 
the box being well padded with a soft pillow, or a well- 
padded posterior splint, or a moulded pasteboard or felt 
gutter may be employed; if either of these dressings is 
employed, the splint or gutter should be long enough to 
extend from the lower part of the leg to the upper part of 
the thigh. 

At the end of two weeks it is well to place the limb in 
a plaster-of- Paris dressing extending from the foot to the 
upper part of the thigh. This dressing should be re- 
tained for four weeks, and at the end of this time the 
dressing should be removed, and if the union is suffi- 
ciently firm to allow the patient to go about on crutches, 
a fresh plaster-of-Paris splint should be applied extending 
from the middle of the leg to the middle of the thigh, or 
lateral splints of pasteboard may be substituted for the 
plaster dressing. 

A certain amount of permanent impairment of the joint 
motion is apt to follow fractures involving one condyle or 
both condyles of the femur. 

Fracture of the Shaft of the Femur in Children. The treat- 
ment of these fractures in infants by extension by a weight 
and pulley and lateral splints is often unsatisfactory on 
account of the difficulty in keeping the patient quiet upon 
his back, and from the soiling of the dressings by the 
feces and the urine. In children two years of age and 
over I have never found much trouble in employing ex- 
tension and lateral support by splints and bran-bags or 
sand-bags, and in these cases I make additional fixation 



368 



FRACTURES. 



Fig. 285. 



at the seat of fracture, and guard against displacement of 
the fragments by the child sitting up in bed when not 
watched, by carefully moulding external and internal 
pasteboard or felt splints to the thigh, and holding them 
in place by the turns of a bandage. I have employed 
this form of dressing even in children under two years of 
age with the most satisfactory results. 

In cases of fracture of the femur in children from a few 
months to a year or eighteen months of age, in whom it 
is difficult to obtain quietude, or who have to be moved to 
give them nourishment if they are taking the breast, the 
dressing which I have found most satisfactory consists in 
first applying a roller bandage from the foot to the groin, 
and then moulding to the outer half of the foot, leg, 
thigh, and also to half of the pelvis, a pasteboard or felt 
splint which is well padded with cotton, and held in posi- 
tion by the turns of a bandage carried 
from the foot to the pelvis and finished 
with circular turns about the pelvis. 
The splint should be so moulded as to 
include a little more than one-half of 
the circumference of the thigh and 
leg. If this splint becomes soiled it 
is easily replaeed by a fresh one, and 
its removal and renewal are much 
easier than that of the plaster-of-Paris 
splint which is recommended by some 
surgeons in these cases. 

In young children fractures of the 
femur are often incomplete or green- 
stick fractures ; and even when com- 
plete, the shortening is usually not 
Fracture of the femur marked, as the line of fracture is apt 

treated by vertical exten- t be transverse t he periosteum often 
sion (Bryant.) i , i - j 1 • u 

not being completely ruptured, which 
tends to hold the fragments in position. 

In green-stick fractures the deformity should be reduced 
by manipulation, even if it is necessary to convert the incom- 
plete fracture into a complete one to accomplish this object. 




FRACTURES OF THE PATELLA. 369 

Mr. Bryant recommends that fractures of the femur in 
young children be treated in the vertical position ; the in- 
jured limb, together with the sound one, is flexed at a 
right angle to the pelvis and fixed with a light splint, and 
attached to a cradle or bar above the bed (Fig. 285). 

If the plaster-of-Paris dressing is used, the limb should 
be first enveloped from the foot to the pelvis with a flan- 
nel bandage, and extension should be made while the 
plaster-of-Paris bandage is being applied, and should be 
kept up until the bandage has become fixed. The plaster 
bandage should extend from the toes to the pelvis, and it 
is well to fix the hip-joint by carrying several turns of the 
bandage about the pelvis. To prevent the splint from 
absorbing the discharges and becoming offensive, the upper 
portion of it may be coated with shellac. 

The time required for union in fractures of the femur 
in children is about four weeks, and the dressings may be 
removed at this time; but the child should not be allowed 
to use the limb for several weeks after this period. 

Ambulatory Treatment of Fractures of the Femur. In 
this method of treatment in fractures of the femur the 
injured limb is strongly extended, and a flannel roller is 
applied to the leg, thigh, and pelvis. A plaster-of-Paris 
bandage is then applied from the toes to the pelvis, and 
is made to include the pelvis by spica and circular turns. 
It should be well padded in the perineum, and the inner 
portion of the bandage should fit well in the region of the 
tuberosity of the ischium. The plaster dressing should be 
so applied that upon the patient standing upon the limb 
the weight is supported by the plaster cast resting upon the 
tuberosity of the ischium and the expanded portion of the 
ilium. A Taylor hip-splint, reinforced by plaster bandages 
and the use of crutches, with a high shoe on the sound 
foot, may be used in the ambulatory treatment of fractures 
of the femur. 

Fractures of the Patella. The dressing of fractures of 
the patella consists, first, in the application of a roller 
bandage from the toes to the upper part of the leg; a well- 
padded posterior wooden splint long enough to extend from 

24 



370 



FRACTURES. 



the middle of the leg to the middle of the thigh, or an Agnew 
splint, which is provided with pegs for the attachment of 
strips of adhesive plaster (Pig. 286), is next placed under the 
limb. A small compress of lint is next placed above the 
upper fragment, and a similar compress is placed below 



Fig. 286. 




Agnew's splint for fracture of the patella. 

the lower fragment; a strip of adhesive plaster one and a 
half inches in width and twenty-four inches in length has 
its middle portion applied over the compress, and its ends 
are then brought obliquely downward and fastened to the 
splint, or to the pegs if Agnew's splint be used; this may 
be reinforced by a second or third strip. The object of 

Fig. 287. 




ililillM " 

Agnew's splint applied. 

these strips is to bring the upper fragment down in con- 
tact with the lower fragment. A strip of plaster with the 
ends passing in the opposite direction is next placed over 
the lower compress, and the ends are fastened to the splint 
or pegs; this strip serves only to steady the lower frag- 



FBA CT UBES OF THE PA TELL A . 371 

ment, as it cannot be drawn upward to meet the upper 
fragment l»y reason of the inextensibility of its ligament- 
ous attachment (Fig. 287). If the Agnew splint is em- 
ployed the strips of plaster may be tightened by turning 
the pegs to which they are fastened without removing the 
splint. 

The splint is next firmly fixed in contact with the limb 
by the turns of a roller bandage extending from the lower 
to the upper end of the splint. The limb should next be 
placed upon an inclined plane or in a long fracture-box, 
with its foot elevated to relax the quadriceps femoris 
muscle. This dressing should be removed and reapplied 
in a few days, as the dressings become loose as the swell- 
ing about the seat of injury subsides, and after this disap- 
pears the dressings require renewal at less frequent inter- 
vals; aud usually at the end of three weeks the splint may 
be removed and a plaster-of-Paris bandage may be applied, 
extending from the middle of the leg to the middle of the 
thigh. At the end of six weeks the patient may be allowed 
to walk upon the limb, the knee-joint being fixed with a 
plaster-of-Paris or pasteboard splint. 

It is well, after removal of the splints, for the patient 
to wear for some months a laced muslin knee-supporter, 
which gives some support to the knee-joint. 

The union in fractures of the patella is usually fibrous, 
although in rare cases bony union has occurred. 

A great variety of splints have been devised and used 
in the treatment of fractures of the patella, the main object 
of which is to fix the knee-joint and bring the fragments as 
nearly as possible in apposition. Malgaigne's hooks, or 
Levis' s modification of the same, are employed by some 
surgeons to secure close apposition of the fragments. The 
method of treatment in fractures of the patella, which con- 
sists in exposing the fragments by an incision and drilling 
and suturing them with catgut or silver-wire sutures, is 
also employed at the present time, the strictest antiseptic 
precautions being taken to prevent infection of the wound. 
In cases of rupture of the fibrous union after fracture of 
the patella, which is not an uncommon accident, the treat- 



372 



FRACTURES. 



ment of the case should be the same as that for a recent 
fracture of the patella. 

Fractures of the Bones of the Leg. In fractures of 
both bones of the leg the displacement is usually very 
marked. When one bone only is broken, the sound bone, 
acting as a splint, prevents much deformity, except in case 
of fracture at the lower end of the fibula, when the foot 
inclines to the injured side. 

The dressing of fractures of both bones of the leg, or 
of fracture of the tibia or fibula alone, except in cases 
where the lower portion of the fibula is the seat of injury, 
is best accomplished by the use of a fracture-box. The 



Fig. 288. 




Application of the fracture-box. 



displacement being overcome as far as possible by exten- 
sion and manipulation, the leg is placed in a fracture-box, 
which is prepared for the reception of the limb by having 
the sides let down and having a soft pillow laid in it; the 
foot is next secured to the footboard by a loop of bandage 
passed around the foot, the ends being tied after passing 
through the slots in the footboard; a pad of oakum or 
cotton is placed under the tendo-Achillis, to relieve the 
heel from pressure, and a similar pad is placed between 
the sole of the foot and the footboard (Fig. 288). The 
sides of the box are then brought up and secured by two 
or three strips of bandage tied around the box. In using 



FRACTURES OF THE BONES OF THE LEG. 373 

a fracture-box in the treatment of fractures of the bones 
of the leg the surgeon should see that the foot is kept well 
down to the footboard and is at a right angle with the leg, 
that there is no eversion of the knee, and that the pillow 
is full enough to make equable pressure upon the leg when 
the sides of the box are secured, and that the heel is not 
subjected to undue pressure — the use of a pad of oakum 
or cotton under the tendo-Achillis being employed to pre- 
vent this complication. Where there is a tendency to 
tilting upward of the lower end of the upper fragment 
the lower fragment can be brought in line with this by 
raising the foot by a mass of oakum or cotton placed under 
the tendo-Achillis and heel, and so overcoming the defor- 
mity. In some cases division of the tendo-Achillis may 
be required before this deformity can be corrected. 

The subsequent dressings of the case are conducted by 
letting down the sides of the box and correcting any dis- 



FlG. 289. 






_,■ ' 



Plaster bandage applied to fracture of the leg. 

placement, if present, by adjusting the limb and pads in 
their proper position, and again bringing up the sides of 
the box and securing them. At the end of two weeks the 
fracture-box may be removed and a plaster-of-Paris dress- 
ing may be applied to the limb, which will allow the 
patient more freedom of movement in bed, or permit of 
his sitting up without disturbing the fragments (Fig. 289). 



374 



FRACTURES. 



Union in fracture of the bones of the leg is usually 
quite firm in six weeks, but the patient should not be 
allowed to put his weight upon the limb in walking for at 
least eight weeks. 

If the patient is restless, and finds his position with the 
fracture-box resting upon the bed irksome, the fracture- 
box may be swung from a frame fastened over the bed 
(Fig. 290). 



Fig. 290. 




Fracture-box suspended. (Agnew.) 



The application of a plaster-of-Paris dressing as a pri- 
mary dressing — the ordinary plaster-of-Paris bandage or 
the Bavarian dressing being applied — in fractures of the 
bones of the leg is adopted by some surgeons, and, if em- 



FRACTURES OF THE BONES OF THE LEG. 375 

ployed, the case should be under constant supervision for a 
few days, so that the dressing can be removed if a danger- 
ous amount of swelling takes place. Moulded splints of 
felt or pasteboard are also sometimes applied in the treat- 
ment of these cases (Fig. 291). 



Fig. 291. 




■■■ : W^ 
Moulded binder's board splints for fracture of the leg. 



Ambulatory Treatment of Fractures of the Bones of the Leg. 
The application of a dressing for the ambulatory treat- 
ment in fractures of the bones of the leg is as follows : 
The fracture should be reduced and the skin of the leg 
carefully washed with soap and water; a flannel bandage 
is then applied from the toes to a point just above the knee. 
This bandage holds to the sole of the foot a number of 
layers of cotton wadding, which, when moderately com- 



376 FRACTURES. 

pressed, makes a pad three-quarters of an inch in thickness. 
A plaster- of- Paris bandage is applied to the foot and leg, 
and extends above the knee, and care should be taken to 
apply additional turns about the sole of the foot and ankle, 
to give it greater strength at these points. The turns of 
the bandage should also be firmly applied about the ex- 
panded head of the tibia. 

In the ambulatory method of treatment, the patient, as 
soon as the bandage has become firm, is allowed to walk 
about, first with crutches or a cane, and finally bearing 
his weight upon the injured limb. 

In patients suffering with delirium tremens, or in mani- 
acal patients, the use of a fracture-box in the treatment of 
fractures of the bones of the leg is often not satisfactory, 
on account of the difficulty in restraining the movements 
of the patient and the consequent displacement of the 
fragments. In such cases it is well to apply a few strips 
of binder's board, well padded with cotton, to the limb, 
extending above and below the seat of the fracture, hold- 
ing them in place by a few turns of a roller, and then to 
wrap the limb and foot in a soft pillow, and hold this in 
place by the turns of a roller bandage applied with mod- 
erate firmness. This dressing allows the patient to move 
the limb without serious disturbance of the fragments, and, 
after the patient recovers from his attack, the leg may be 
placed in the fracture-box or in a plaster-of-Paris dressing. 

In fractures of the bones of the leg in young children 
the same difficulty is often experienced in keeping them 
quiet, and for this reason a fracture-box cannot be used 
with satisfaction. In dressing these cases, two lateral 
splints of pasteboard, moulded to the foot and leg and 
well padded with cotton, may often be employed with the 
best results. The splints should not be wide enough to 
meet on the anterior or posterior surface of the leg or foot. 
The splints, after beiug carefully adjusted, are held in 
place by the turns of a roller bandage; and, after these 
splints have been applied for two weeks, and all swelling 
has subsided at the seat of fracture, a plaster-of-Paris 
bandage may be substituted for them, which should be 



FRACTURES OF THE FIBULA. 377 

worn for three weeks; at the expiration of this time union 
is usually firm enough to dispense with all dressings. 

Fractures of the" Fibula. In fractures of the fibula, 
with the exception of that fracture occurring at the lower 
end of the bone, the deformity is not marked, and they are 
usually dressed with a fracture- box applied as in the dress- 
ing of fractures of both bones of the leg, and at the end 
of two weeks a plaster-of-Paris dressing should be applied, 
and the patient may be allowed to get out of bed and move 
about on crutches. The union in a fracture of the fibula 
is usually quite firm at the end of five weeks, and all 
dressings may be dispensed with at that time. 

Fracture of the Lower End of the Fibula (Pott's Fracture). 
This fracture usually occurs in the lower fifth of the bone, 
and is often associated with a laceration of the internal 
lateral ligament of the ankle-joint or a sprain-fracture 
of the internal malleolus, and is usually accompanied by 
marked eversion of the foot. 

In this fracture, after reducing the displacement by ex- 
tension and manipulation, the limb should be placed in a 
fracture-box provided with a soft pillow, the foot should 
be secured to the footboard, and a pad of oakum or 
cotton should be placed under the tendo-Achillis; before 
bringing up the sides of the box and securing them, 
two firm compresses of lint or oakum should be placed in 
contact with the leg and foot, one just above the inner 
malleolus, the other just below the outer malleolus. The 
sides of the box are next brought up and secured, and by 
the pressure of these compresses the foot is brought into 
an inverted position and the deformity is corrected. 

The after-dressing of this fracture consists in letting 
down the sides of the box, and in inspecting the parts to 
see that the foot is kept in the proper position, and care 
should be taken to see that undue pressure is not made 
upon the skin by the compresses, which might result in 
ulceration; this may be avoided by sponging the skin with 
alcohol and changing the positions of the compresses 
slightly at each dressing. At the expiration of ten days 
the fracture-box and compresses may be removed and the 



378 FRACTURES. 

limb may be put up in a plaster-of-Paris dressing, includ- 
ing the foot and leg, up to the knee. The patient may 
then be allowed to go about on crutches, and at the end of 
five weeks all dressings may be dispensed with. 

This fracture is also dressed by means of Dupuytren's 
splint, which consists of a straight wooden splint long 
enough to extend from the condyles of the femur to the 
end of the toes; this splint is provided with padding, the 
thickest part of which, several inches in thickness, should 
rest upon the skin just above the inner malleolus when the 
splint is applied to the inner side of the leg. The splint 
is secured in position by the turns of a roller applied 

Fig. 292. 







Dupuytren's splint applied. 

over the foot and at the upper part of the leg (Fig. 292). 
After using this dressing for a few days, if the displace- 
ment is satisfactorily corrected, the splint may be removed 
and the leg may be placed in a fracture-box or in a plas- 
ter-of-Paris dressing. 

Fractures of the Tarsal Bones. The calcaneum and 
astragalus are the tarsal bones most frequently fractured. 
The dressing of fractures of the calcaneum, after reducing 
the displacement, which is not usually marked unless the 
posterior portion of the bone is involved, by manipulation, 
consists in placing the leg and foot in a fracture -box, and 
care should be taken to see that the foot is kept at a right 
angle to the leg. When the fracture involves the poste- 
rior portion of the bone, and there is displacement by the 
action of the muscles inserted into the fragment, the leg 
should be flexed upon the thigh and the foot should be 
extended; this position may be maintained by applying 



FRACTURES OF PHALANGES OF THE TOES. 379 

a well-padded curved splint to the anterior portion of the 
leg and foot and securing it in position by a bandage. 

Fractures of the astragalus, after reducing any defor- 
mity which is present by extension and manipulation, are 
dressed by placing the foot and leg in a fracture-box, care 
being taken to see that the foot is kept at a right angle to 
the leg. This precaution is important, as anchylosis not 
infrequently occurs after this fracture, and if the foot is 
in the proper position it is much more useful to the patient. 

As soon as the swelling, which is usually very marked 
after fracture of the calcaneum or astragalus, subsides, the 
foot and leg should be put up in a plaster-of-Paris ban- 
dage. The amount of tension and the inability to reduce 
the displacement in cases of fracture of the astragalus may 
be indications for excision of the fractured bone. The 
time required for union in fractures of the tarsal bones is 
from five to six weeks. 

Fractures of the Metatarsal Bones. These fractures 
are dressed by placing the foot upon a well-padded plantar 
splint, and using compresses to hold the fragments in place 
if there is much displacement, the splint and compresses 
being held in position by a bandage; or they may be 
treated by placing the foot and leg in a fracture-box, the 
footboard of the box acting as a plantar splint; the plaster- 
of-Paris dressing may also be used in these cases. The 
time required for union in fracture of the metatarsal bones 
is from three to four weeks. 

Fractures of the Phalanges of the Toes. These frac- 
tures are often compound and attended with so much 
laceration of the soft parts that immediate amputation is 
required; when, however, the fractures are simple, or in 
compound fractures where amputation is not required, the 
dressing consists in applying a plantar splint of wood or 
binder's board, extending beyond the toes and securing it 
in position by the turns of a roller bandage. When a 
single toe only is broken a moulded splint of gutta-percha 
or binder's board may be applied, and a portion of the 
splint should extend some distance upon the sole of the 
foot, to fix the proximal joint, and also to give the toe a 



380 FRACTURES. 

firm point of fixation; the moulded splint should be held 
in position by a narrow roller bandage or by strips of ad- 
hesive plaster. The time required for union in fractures 
of the phalanges of the toes is about three weeks. 

Dressing of Compound or Open Fractures. 

In the dressing of compound or open fractures the same 
dressings and splints which are generally used in the treat- 
ment of simple or closed fractures may be employed; the 
wound in the soft parts requires a special dressing, and this 
should be so arranged as to secure free drainage and pro- 
mote its prompt healing. In some cases of compound 
fracture the treatment of the injuries of the soft parts de- 
mands attention first, and in such cases the injury to the 
bones is for a time disregarded, care being taken to see 
that the fragments are kept quiet, so as to prevent further 
damage to the soft parts until the wound is in such a con- 
dition that the proper manipulation to reduce the displace- 
ment and fix the fragments by splints and suitable dress- 
ings can be undertaken without interfering with the repair 
of the wound. 

In the dressing of compound or open fractures the skin 
surrounding the wound should be first carefully cleansed, 
and the wound should next be thoroughly irrigated with 
a 1 : 2000 bichloride solution, and any foreign bodies or 
loose fragments of bone should be removed, and if there 
is hemorrhage it should be controlled by securing the 
bleeding vessels with ligatures. The reduction of the dis- 
placement should next be accomplished by making exten- 
sion and by manipulation; if the fragments project from 
the wound before this can be satisfactorily accomplished, 
it may be necessary to enlarge the wound and to resect one 
or both ends of the fractured bones, and in some cases it 
may be necessary to drill the ends of the fragments and 
introduce a strong wire or catgut suture, or a metallic nail, 
screw, or plate, to hold them in their proper positions. 
After reduction of the displacement the wound should 
again be thoroughly irrigated with the antiseptic solution, 



DRESSING OF COMPOUND OR OPEN FRACTURES. 381 

and after making provision for drainage by the intro- 
duction of a drainage-tube or tubes, counter-openings 
being made to secure free drainage if necessary, sterilized 
or antiseptic gauze dressings should be applied. 

The wound, if a small one, need not be closed with 
sutures; but if extensive, a few catgut, silk, or silkworm- 
gut sutures may be applied to bring the edges of the wound 
into apposition, care being taken to avoid making undue 
tension; if the soft parts have been much lacerated or 
contused, it is better to introduce no sutures. If the 
limb is much swollen and the wound is a small one, free 
division of the deep fascia to relieve tension and secure 
drainage is often followed by good results. A final irri- 
gation of the wound through the drainage-tube is next 
made, and the wound is covered by a bichloride gauze 
dressing and cohered by a number of layers of bichloride 
cotton, the whole dressing being held in position by a 
gauze bandage applied with moderate firmness. 

The reduction of the fragments and the dressing of 
the wound having been accomplished as has been de- 
scribed, the splints appropriate for a similar fracture, 
if it were a simple or closed one, are next applied. If the 
surgeon has been able to render the wound aseptic, and 
has applied an antiseptic dressing, the compound fracture 
is often soon converted into a simple one by the prompt 
healing of the wound, and the patient may exhibit no more 
constitutional disturbance than he would have with a sim- 
ilar simple or closed fracture. The redressing of a com- 
pound fracture dressed in this way need not be made for a 
week or ten days, unless there is a rise in the patient's 
temperature or the dressings become soaked with discharges 
from the wound, or they become uncomfortable to the pa- 
tient by reason of swelling of the soft parts in the region 
of the wound. When the redressing of the fracture be- 
comes necessary the dressings are removed, and the drain- 
age-tubes may be removed if no longer needed; the wound 
being redressed with an antiseptic dressing, the splints are 
reapplied, and, after the wound is healed, the subsequent 
dressing of the fracture should be the same as that of a 



382 



FRACTURES. 



simple fracture. The time required for uuion in a com- 
pound fracture is usually much longer than in a corre- 
sponding simple fracture. 

Plaster-of-Paris Dressing. This may be used as a primary 
dressing in compound fractures; the displacement being 
reduced and the wound being dressed with an antiseptic 
gauze dressing, a plaster-of -Paris bandage is applied to the 
parts so as to firmly fix the fragments; the joints on either 
side of the fracture should be fixed by the bandage, and 
the parts should be held in position until the plaster has 
set firmly. After the plaster has become firm a fenestrum 



Fig. 293 




Fenestrated plaster dressing for compound fracture of the leg. (Stimson.) 



should be made over the position of the wound, so that it 
can be inspected or dressed through this when necessary. 
The ends of a piece of stout wire, bent into a semicircle, 
may be incorporated in the turus of the plaster bandage 
above and below the position of the fenestrum, to give it 
additional strength after the removal of a portion of the 
bandage to make the fenestrum (Fig. 293). 

If the plaster- of -Paris dressing is applied as a primary 
dressing in compound fractures the case should be carefully 
w r atched for a few days, and if much swelling occurs at the 
seat of fracture its removal and renewal are indicated: 



DRESSING OF COMPOUND OB OPEN FRACTURES. 383 

profuse discharge of serum may also soak the dressings 
and bandage so that its renewal is necessitated. Some 
surgeons, therefore, prefer to defer the application of the 
plaster-of-Paris dressing in compound fractures for a few 
weeks until the swelling has diminished and the wound is 
nearly or quite healed; the wound being covered with an 
antiseptic dressing, the plaster bandage is applied and a 
fenestrum is made over the position of the wound if 
required. 

Binder's Board or Felt Splints. These may also be em- 
ployed in the dressing of compound fractures, being 
moulded to the parts after an antiseptic dressing has been 
applied to the wound, and held in position by the turns of 
a roller bandage. 

The principal advantage in the use of these splints is 
the ease with which they can be removed and reapplied if 
frequent dressings of the fracture are necessary for any 
reason. They may be used during the entire course of 
treatment, or, after a few weeks, when the swelling has 
diminished at the seat of fracture and the wound is well 
advanced toward repair, they may be discarded and a 
plaster-of-Paris dressing substituted. In compound frac- 
tures of the bones of the leg, after reducing the displace- 
ment and applying an antiseptic dressing to the wound, I 
usually apply moulded binder's board splints to either side 
of the leg, including the foot, and place the leg in a frac- 
ture-box for additional security, and after a few weeks I 
discard the binder's board splints and apply a plaster-of- 
Paris dressing. 

A method of dressing compound fractures which has 
been introduced by Mr. Treves consists in rendering the 
skin in the region of the wound aseptic and removing any 
foreign bodies from the wound, then rendering it as far as 
possible aseptic; iodoform is then dusted thickly over the 
wound at intervals, and, mixing with the blood and serum 
from the wound, is allowed to dry, forming an antiseptic 
scab, the wound being exposed to the air, and the frag- 
ments are retained in position by splints or by a fracture- 
box. 



384 



FRACTURES. 



Ununited Fractures. This condition usually arises 
from local causes, such as imperfect coaptation of the 
fragments, the interposition of muscular tissue, fascia, 
tendon, or nerve, or a portion of devitalized bone between 
the fragmeuts. The ends of the bones may be rounded, 
or may be united by fibrous tissue, or there may be an 
attempt at the formation of a false-joint, the end of one 
fragment beiug rounded off and the other cupped to re- 
receive it. 

The treatment of ununited fracture consists in exposing 
the ends of the bones by incision, with full antiseptic pre- 



FlG. 294. 



Fig. 295. 





Fragments in ununited fracture 
secured by silver wire. 



Fragments in ununited fracture 
secured by silver splint. 



cautions, and removing the ends of the bones to secure a 
healthy surface, and then fixing the fragments securely 
together by drilling them and introducing one or more 
heavy silver- wire sutures (Fig. 294). In some cases the 
shape of the fragments is such that the bones can be sawed 
so as to form a mortise, and the fragments can then be fixed 



UNUNITED FRACTURES. 385 

by the introduction of one or more steel or silver screws. 
Another method of fixation is by a steel or silver splint 
secured to the fragments by iron or silver screws (Fig. 
295). After the fixation of the fragments has been accom- 
plished, the wound should be closed and an antiseptic 
dressing applied, and additional fixation is furnished by 
the application of a plaster- of -Paris dressing. 



25 



PAET IV. 

DISLOCATIONS 



Dislocation. This is the displacement of the articular 
surfaces of the bones which enter into the formation of a 
joint. 

Dislocations may be complete, partial, simple, compound, 
and complicated, and they are also known as recent and old 
dislocations. 

Complete Dislocation. This is a dislocation in which no 
portions of the articular surfaces of the bones remain iu 
contact with each other. 

Partial Dislocation. This is a dislocation in which por- 
tions of the articular surfaces of the bones still remain in 
contact with each other. 

Simple Dislocation. This is a dislocation in which there 
exists displacement in the relation of the articular sur- 
faces of the bones with little injury to the soft parts ad- 
jacent to the joint, and the displaced ends of the bones 
do not communicate with the air by a wound in the soft 
parts. 

Compound Dislocation. This is a dislocation in which 
there exists displacement of the articular surfaces of the 
bones which communicate with the air through a wound 
in the soft parts. 

Complicated Dislocation. This is a dislocation in which, 
in addition to the displacement of the articular surfaces of 
the bones, there exists a fracture, or a laceration of impor- 
tant bloodvessels, nerves, or muscles in proximity to the 
dislocation. 



TREATMENT OF DISLOCATIONS. 387 

Recent Dislocation. This is a dislocation in which the 
displacement of the articulating surfaces of the bones has 
existed for such a period that time has not been afforded 
for inflammatory changes to take place in the articular 
surfaces of the bones or in the adjacent tissues which 
would seriously interfere with their reduction. 

Old Dislocation. This is a dislocation in which the dis- 
placement of the articulating surfaces of the bones has 
existed for some time, and in this variety of dislocation 
the displaced bones often form firm adhesions to the sur- 
rounding tissues, and the articulating surfaces often un- 
dergo changes. 

Treatment of Dislocations. The first indication in 
the treatment of dislocations is to return the displaced 
articular surfaces of the bones to their normal position 
and to retain them in this position by the use of suitable 
dressings. The return of the articular surfaces of the 
bones to their normal position or the reduction of the dis- 
location is accomplished by manipulation, extension, and 
counter-extension. The reduction of dislocations should 
be attempted as soon as possible after they have occurred. 

The principal obstacles to the reduction of dislocations 
are muscular resistance and the anatomical peculiarities of 
the joints. The former is best overcome by the use of an 
ancesthetic given to the point where complete muscular 
relaxation is produced. The resistance offered by the 
changed relations of the articular surfaces and the liga- 
ments is to be overcome by the surgeon making such 
manipulations, founded upon his knowledge of the anat- 
omy of the parts, as will make the ligaments, muscles, 
and bones assist in the reduction of the dislocation. 

In recent dislocations, by the use of extension and 
manipulation, especially if an anaesthetic be employed, the 
reduction is usually accomplished without the use of much 
force; but in old dislocations, where absolute muscular 
shortening has taken place, the use of extending bands is 
often required, and in securing these bands to the limb the 
clove-hitch knot is useful (Fig. 296). 

The treatment of dislocations after reduction consists in 



388 DISLOCATIONS. 

placing the joint at complete rest by the application of 
suitable splints and bandages, and in treating any inflam- 
matory complications, if they arise, by the application of 

Fig. 296. 




Clove-hitch knot applied. (Erichsen.) 

evaporating lotions, and in a week or two after the injured 
ligaments have been repaired, passive motion should be 
resorted to for restoring the function of the joint. 

Special Dislocations. 

Dislocations of the Vertebrae. Dislocations of the 
lumbar and dorsal vertebra?, as simple dislocations, are 
extremely rare accidents; they are occasionally met with, 
but are more often associated with fractures of the verte- 
brae in these regions; their occurrence in the cervical ver- 
tebrae is more common. The treatment of dislocations of 
the vertebrae, whether complicated with fracture or not, 
consists in attempting reduction by making extension and 
counter-extension with manipulation, and by this means, in 
many cases, the luxations can be reduced. If, however, 
the efforts at reduction are unsuccessful, permanent exten- 
sion should be applied by means of a weight-extension 
apparatus from both legs and from the shoulders and 
head. The after-treatment consists in keeping the patient 
at rest upon his back in bed upon a firm mattress, and if 
the cervical vertebrae have been involved, the head and 
neck should be supported by short sand-bags; and in case 



JDISL CA TIONS OF THE L WEB J A W. 



389 



of the vertebrae below this point, the application of a 
plaster-of-Paris jacket may be used 1o give support and 
fixation to the parts. The general management of the 
case as regards complications is similar to that in cases of 
fracture of the vertebrae. 

Dislocations of the Coccyx. These are reduced by 
manipulations with the finger in the rectum and external 
manipulation at the same time. The only after-treatment 
required is rest in bed for a few days and the administra- 
tion of opium to keep the bowels quiet. 

Fig. 297. 




Bilateral dislocation of the jaw. (Ashhurst.) 



Dislocations of the Lower Jaw. These dislocations may 
consist in the displacement of one or both condyles of the 
lower jaw from the glenoid fossae, constituting the unilat- 
eral or bilateral dislocation of the jaw; the latter is the 
more common form of dislocation of the jaw met with, 
and the deformity resulting is shown in Fig. 297. 

The reduction of a dislocation of the lower jaw is accom- 



390 DISL CA TIONS. 

plished as follows : The surgeon placing his thumbs, well 
protected by strips of bandage or a towel, on the molar 
teeth or behind them, presses the angles of the jaw down- 
ward while he elevates the chin with his fingers, and by 
this manipulation the condyles of the jaw usually slip back 
into place with a snap (Fig. 298). After reduction of the 

Fig. 298. 




Method of reducing dislocation of the lower jaw. (Hamilton.) 

dislocation the jaw should be fixed for a week or ten days 
by the application of a Barton's bandage or a four-tailed 
sling. 

Dislocation of the Hyoid Bone. A few cases of dis- 
locations of the hyoid bone have been recorded; the treat- 
ment consists in throwing back the head as far as possible, 
to place the muscles of the neck upon the stretch, depress- 
ing the lower jaw, and pressing the luxated bone into 
position. 

Dislocations of the Ribs. The ribs may be dislocated 
at their vertebral articulations or at the junction with the 
costal cartilages. The treatment of these dislocations con- 
sists in reducing the displacement by manipulation and 
pressure and then in fixing the chest to secure immobility 
of the ribs by strapping the affected side with strips of 
adhesive plaster, the same dressing being applied as in 
cases of fracture of the ribs, the dressing being retained 
for three or four weeks. 



DISLOCATIONS OF THE CLAVICLE. 391 

Dislocations of the Sternum. Dislocation or diastasis 
of the stern urn may occur at the junction of the manu- 
brium and gladiolus or at the junction of the ensiform 
cartilage and gladiolus. The reduction is effected by ex- 
tension of the chest by bending the dorsal spine over a 
firm cushion placed under the back and by pressure upon 
the projecting bone; when the displaced bone has been 
reduced a compress should be placed over the seat of 
injury, and held in place by broad strips of adhesive 
plaster, or by a bandage to keep the parts at rest. The 
dressing should be retained for three or four weeks. 

In the few examples of dislocations of the ensiform 
cartilage which have been reported, the displacement of 
the cartilage has in some cases given rise to persistent 
vomiting, which w T as relieved by reduction of the displace- 
ment; it is, however, almost impossible to keep the frag- 
ment in place after reduction. 

Dislocations of the Pelvis. Dislocations or diastasis of 
the bones of the pelvis may occur at the pubic or sacro- 
iliac symphyses. 

These are generally serious injuries, as they are apt to 
be complicated by lesions of the pelvic viscera. 

The reduction of these dislocations is effected by pressure 
and manipulation, and after reduction the parts should be 
supported by a compress held in place by a stout binder 
or by broad strips of adhesive plaster, the patient being 
kept quiet in bed and the pelvis being supported by means 
of sand-bags. The dressings should be retained for from 
four to six weeks. 

Dislocations of the Clavicle. Dislocations of the clav- 
icle may occur either at the sternal or acromial end, and 
the latter injury some writers describe as a dislocation of 
the scapula, following the general rule that the distal bone 
is the one dislocated. 

Dislocations of the Sternal End of the Clavicle These 
may occur in a forward, backward, or upward direction, 
and the displacement is generally well marked (Fig. 299). 
The reduction of this dislocation is effected by placing the 
knee against the spine, and drawing the shoulders outward 



392 



DISLOCATIONS. 



and backward and pressing the displaced end of the clavi- 
cle into place. The reduction is generally easy, but it is 
often difficult to keep the end of the bone in its proper posi- 
tion. To accomplish this a compress should be placed over 
the end of the bone, and this should be secured in place 
by broad strips of adhesive plaster; the shoulders should 
be brought well backward and secured by a posterior 



Fig. 299. 



Fig. 300. 





Dislocation of sternal end of clavicle 
forward. (Bryant.) 



Dislocation of clavicle at acromial 
end. (Bryant.) 



figure-of-eight bandage of the chest, and the arm of the 
injured side should be fastened to the side of the chest by 
spiral turns of a bandage. In some cases, in addition to 
the compress over the end of the bone, securing the arm 
of the injured side in the Velpeau position will be found 
all that is necessary to retain the bone in position. 

Dislocation of the Acromial End of the Clavicle. This 
may be upward, downward, or backward (Fig. 300). 
The reduction is effected by manipulation of the arm and 
scapula and by pressure over the displaced end of the 
clavicle. The displacement is usually reduced without 
much trouble, but it is often a matter of difficulty to keep 
the end of the bone in its proper place. 

The dressing consists in placing a compress over the 
acromial end of the clavicle and holding it in place by 



DISLOCATIONS OF THE SHOULDER. 393 

broad strips of adhesive plaster; the arm should at the 
same time be fixed in the Velpeau position. 

Stimson's dressing consists in applying a long strip of 
adhesive plaster three inches wide, the centre being placed 
over the flexed elbow and its ends carried up in front of 
and behind the arm, crossing over the end of the clavicle 
and being secured on the front and back of the chest re- 
spectively, while the bone is held in place by pressure 
upon the clavicle aud the elbow. For additional security 
the forearm may be supported in a sling and the arm 
bound to the side of the chest. 

The dressings after reduction of dislocations of the 
clavicle should be kept in place for at least three weeks. 
Although in many cases a certain amount of deformity 
persists, the disability resulting from the injury is not 
often marked. 

Dislocations of the Scapula. Dislocation of the acro- 
mion process of the scapula from the outer end of the 
clavicle, which has been described under dislocations of 
the acromial end of the clavicle, is classed by some writers 
as a scapular dislocation. 

Dislocation or Projection of the Inferior Angle of the Scap- 
ula. This is caused by the escape of the inferior angle of 
the scapula from under the latissimus dorsi muscle or is 
due to relaxation of this muscle and of the serratus mag- 
nus, sometimes described as a dislocation of the iuferior 
angle of the scapula. The reduction of this deformity con- 
sists in the employment of manipulation and pressure to 
overcome the displacement, and the use of a compress 
held in place by broad strips of adhesive plaster to secure 
the bone in its proper position. 

Dislocations of the Shoulder. The head of the 
humerus may be dislocated downward, forward, or back- 
ward. 

Subglenoid Dislocation of the Head of the Humerus. In 
this variety of dislocation the head of the bone rests in 
the axilla (Fig. 301). 

Subcoracoid Dislocation of the Head of the Humerus. 
In this variety of dislocation the head of the humerus 



394 



DISLOCATIONS. 



rests beneath the coracoid process of the scapula (Fig. 
302). 

Subclavicular Dislocation of the Head of the Humerus. 
This may be considered an aggravated form of the latter 
variety of dislocation; the head of the humerus in this 
dislocation rests beneath the clavicle. 

Fig. 301. 




Subglenoid dislocation of the head of the humerus. (Stimson.) 

Subspinous Dislocation of the Head of the Humerus. In 
this variety of dislocation the head of the humerus rests 
beneath the spine of the scapula (Fig. 303). 

Reduction of dislocations of the humerus is effected by 
manipulation, by extension and counter-extension, and by 
a combination of these methods. 

Manipulation in the reduction of subglenoid dislocation 



DISLOCATIONS OF THE SHOULDER. 



395 



of the humerus is practised with the patieut in the recum- 
bent posture by first flexing the forearm upon the arm to 
relax the long head of the biceps muscle; the elbow is 
next seized and abducted so as to bring it to the side of 
the patient's head, thus relaxing the deltoid and supra- 
spinous muscles; the surgeon or an assistant next places 



Fig. 




Subcoracoid dislocation of the head of the humerus. (Stimson. 



his hand upon the head of the humerus in the axilla, and, 
as the arm is drawn outward to a right angle with the 
body by the other hand, he pushes the head of the bone 
into the glenoid cavity. 

In the reduction of subcoracoid aud subclavicular dislo- 
cations the manipulations are the same, except that the arm 
is to be rotated outward before being carried downward. 

In the reduction of subspinous dislocations after the arm 



396 



DISLOCATIONS. 



has been abducted, it should be rotated inward and direct 
pressure should be made upon the head of the bone as the 
arm is adducted. 



Fig. 303. 




Subspinous dislocation of the head of the humerus. (Erichsen.) 

Reduction may also be effected by extension and counter- 
extension, as in Cooper's method, where extension is made 
from the arm downward and counter-extension is made by 
the heel in the axilla (Fig. 304). 

Kocher's method of reduction of dislocations of the shoul- 
der consists in flexing the elbow at a right angle and press- 
ing it closely against the side, the forearm at the same time 
being turned as far as possible away from the trunk. 
While the external rotation is being maintained the elbow 
is carried well forward and upward, and the arm is then 
rotated inward and the elbow is lowered. 

Mothers Method. Reduction by this method may also 
be accomplished by extension made upward, the scapula 
being fixed by the foot or hand placed over the acromion 
process (Fig. 305). 

After reduction of dislocations of the head of the 
humerus the arm should be bound to the side of the body 



DISLOCATIONS OF THE SHOULDER. 



397 



by the turns of a spiral bandage of the chest, or should 
be held against the side by the application of a Velpeau's 
bandage; this dressing should be removed at intervals of 
a few days, and after ten days or two weeks all dressings 



Fig. 304. 




Reduction of dislocation of the humerus hy heel in the axilla. (Erichsen.) 
Fig. 305. 




Reduction of dislocation of the humerus by extension upward. 



398 DISLOCATIONS. 

should be dispensed with, passive motion should be em- 
ployed, and the patient allowed to move the arm. 

Dislocations of the Elbow. Dislocations of the bones 
of the forearm at the elbow may be either backward, for- 
ward, or lateral. The backward dislocation is the most 
common form (Fig. 306). 

Fig. 306. 



Dislocation of both bones of the forearm backward. (Liston.) 

The reduction of backward dislocations is effected by 
making traction upon the forearm and at the same time 
making pressure upon the lower end of the humerus as 
the forearm is flexed upon the arm. 

Or the reduction may be accomplished by bending the 
arm slowly and forcibly over the knee placed upon the 
inner surface of the elbow, so as to press upon the radius 
and ulna, separating them from the humerus and freeing 
the coronoid process from its abnormal position (Fig. 307). 

Lateral dislocations of the bones of the forearm at the 
elbow are reduced by making extension from the forearm, 
and at the same time making direct pressure on the dis- 
placed bones and counter-pressure on the lower end of the 
humerus. 

Forward dislocations of the bones of the forearm at the 
elbow are reduced by making forced flexion at the elbow, 
together with extension and counter-extension, or by mak- 
ing forced extension of the forearm at the elbow, pressing 
the humerus backwards, and suddenly flexing the forearm. 

The dressing, after the reduction of dislocations at the 
elbow, consists in the application of a well-padded ante- 



DISLOCATIONS OF THE ELBOW. 

Fig. 307. 



399 




Reduction with the knee in the bend of the elbow. (Hamilton.) 
Fig. 308. 




Dressing after reduction of dislocation of the elbow. 



400 



DISLOCATIONS. 



rior right-angled or slightly obtuse-angled splint, to keep 
the forearm in a flexed position — the dressing being prac- 
tically the same as that for fractures of the lower end of 
the humerus, with an anterior angular splint (Fig. 308). 
This dressing should be retained for two or three weeks, 
being removed at intervals of several days; after the re- 
moval of the splint passive motion should be practised, 
to prevent stiffness of the elbow-joint. 

Dislocations of the Head of the Radius. The head of 
the radius may be displaced forward, outward, or back- 
ward, the forward dislocation being the most frequent 
(Fig. 309). The reduction of these dislocations is effected 

Fig. 309. 




Dislocation of the head of the radius forward. (Liston.) 



by making extension from the forearm and counter-exten- 
sion from the lower end of the humerus, and at the same 
time the head of the bone is pressed into its proper posi- 
tion. The dressing after reduction of the displacements 
consists in the application of a compress over the head of 
the bone, and the arm and forearm should be placed upon 
a well-padded anterior angular splint, which is secured by 
a roller bandage. The dressing is similar to that em- 
ployed after reduction of dislocations of the bones of the 
forearm at the elbow. Difficulty is sometimes experienced 



DISLOCATIONS OF THE WRIST. 



401 



in keeping the head of the bone in position after reduction, 
so that the use of a compress in addition to the use of 
the splint is often required. The arm should be kept upon 
the splint for three weeks, being redressed at intervals. 

Dislocation of the Upper End of the Ulna. The 
upper end of the ulna may be displaced backward, the 
olecranon projecting beyond the condyles of the humerus, 
while the head of the radius occupies its normal position. 

The reduction of this displacement is effected in the same 
manner as that of both bones of the forearm backward, 
and the dressing after reduction is similar to that employed 
when both bones have been displaced. 

Dislocations of the Wrist. Dislocations of the carpus 
from the bones of the forearm may he forward (Fig. 310) 
or backward (Fig. 311). The reduction in either variety 



Fig. 310. 



Fig. 811. 





Dislocation of the carpus forward. 
(Hamilton.) 



Dislocation of the carpus backward. 
(Hamilton.) 



of displacement is effected by extension from the hand and 
by pressure. After reduction of the displacement, which 
does not tend to recur, the hand and the forearm should 
be placed upon a well-padded straight splint applied to 
the palmar surface of the hand and forearm. The splint 
should be retained for ten days or two weeks. 

26 



402 DISLOCATIONS. 

The lower end of the ulna may be dislocated from the 
radius forward, backward, or inward. The reduction of 
these displacements is effected by fixing the radius and 
pushing the ulna back into place. The dressing after 
reduction consists in placing the wrist-joint at rest by the 
application of well-padded anterior and posterior straight 
splints. The splints should be retained for three or four 
weeks, dressings being made at intervals of two or three 
days. 

Dislocations of the Bones of the Carpus. The displace- 
ment of the individual bones of the carpus occasionally takes 
place, the os magnum, the semilunar, and pisiform being the 
bones most usually displaced, although other bones of the 
carpus are sometimes dislocated. Reduction is effected by 
means of extension and pressure, and the part should after- 
ward be dressed with a palmar splint and compresses. 

Dislocations of the Metacarpal Bones. The metacar- 
pal bones may be dislocated from the carpus; the bones 
most commonly displaced are those of the thumb and of 
the index and middle fingers; the latter are usually dis- 
placed backward, while the metacarpal bone of the thumb 
may go either backward or forward. 

Reduction is effected by extension and pressure. The 
dressing after reduction consists in the application of a 
palmar splint to the hand and forearm and a compress 
over the displaced bone. The dressings should be re- 
tained for two weeks. 

Fig. 312. 




Backward dislocation of phalanx. Reduction by extension. (Hamilton.) 

Dislocations of the Fingers. Dislocations of the 
phalanges of the fingers usually take place at the metacarpo- 



DISLOCATIONS OF TEE FINGERS. 



403 



phalangeal junction, but sometimes occur at the inter- 
phalangeal joints. The reduction is usually easily effected 
by extension (Fig. 312), or by pushing the phalanx back 
until it stands perpendicularly upon the metacarpal bone, 
when by strong pressure upon its base, from behind 
forward, it is readily carried by flexion into its natural 
position. 

Where difficulty is experienced in making extension in 
the reduction of these dislocations, the ingenious apparatus 

Fig. 313. 




Levis's apparatus for dislocation of the phalanges applied 



of the late Dr. Levis (Fig. 313), or the " Indian puzzle" 
apparatus (Fig. 314), may be employed with success. 



Fig. 314. 




Extension by Indian puzzle. (Bryamt.) 



In dislocations of the proximal phalanx of the thumb back- 
ward (Fig. 315) great difficulty in reduction is often ex- 
perienced from the head of the metacarpal bone slipping 
between the two heads of the short flexor muscle, or be- 
tween the lateral ligaments. The interposition of the 
external sesamoid bone is considered by some surgeons to 
be the cause of difficulty in the reduction of this displace- 
ment. 

In this dislocation reduction is effected by firmly press- 
ing the metacarpal bone of the thumb strongly toward the 
palm of the hand to relax the two portions of the short 



404 



DISLOCATIONS. 



flexor muscle. The thumb is next extended upon the 
wrist until its tip points to the elbow. An assistant next 
places his finger behind the proximal phalanx to prevent 
its slipping backward, and by bringing the thumb down 
to the flexed position the bone slips into place. It some- 
times happens that all efforts at reduction fail, and in such 
cases it may be necessary to divide one head of the short 
flexor muscle subcutaneously or through an open wound 
before the displacement can be relieved. 



Fig. 315. 







Dislocation of proximal phalanx of thumb backward. (Farabeuf.) 

The dressing of dislocations of the phalanges after re- 
duction consists in the application of splints of wood, or 
moulded splints of binder's board, or gutta-percha, to fix 
the joint, which should be retained for ten days or two 
weeks. 

Dislocations of the Hip. The head of the femur is 
most frequently dislocated backward, downward, or up- 
ward, although it may assume other positions in excep- 
tional cases. 

Posterior or Backward Dislocations of the Head of the 
Femur. These are either backward and upward, when 
they are described as iliac or dorsal, the bone resting upon 
the dorsum of the ilium (Fig. 316); or the dislocation may 
be backward, the head of the bone resting uppn the ischi- 
atic notch; these are known as ischiatic dislocations, or dis- 



DISLOCATIONS OF THE HIP. 



405 



locations of the femur, dorsal below the tendon (of the 
obturator interims), according to Bigelow (Fig. 317). 

The reduction of the posterior dislocations of the femur 
can generally be effected by manipulation. The patient 



Fig. 316. 



Fig. 317. 





Backward and upward dislocation 
of femur. (Cooper.) 



Backward dislocation of femur. 
(Cooper.) 



being anaesthetized and placed upon his back, the surgeon 
grasps the leg at the ankle and knee, flexes the leg upon 
the thigh, and the thigh upon the pelvis in the position 
of adduction; he then abducts the limb and rotates it 
outward, briuging it in a broad sweep across the abdo- 
men, and by bringing it down to its natural position the 
head of the bone will slip into the acetabulum (Fig. 318). 



406 DISLOCATIONS. 

Allis, in the reduction of dorsal dislocations, recom- 
mends that, while the patient is supine, the surgeon kneel 
beside him, and in the case of the right arm grasp the 
ankle with the right hand and place the bent elbow of the 

Fig. 318. 




Reduction of backward dislocation of the femur. (Btgelow.) 

left arm beneath the knee. He then turns the bent leg 
outward by means of the ankle and lifts upward, and 
next turns the leg inward and brings the femur down in 
extension. 

Downward and Forward Dislocation of the Head of the 
Femur. In this variety of dislocation the head of the bone 
rests upon the thyroid foramen; this form of displacement 
is sometimes spoken of as a thyroid dislocation (Fig. 319). 

The reduction of downward and forward dislocations of 
the head of the femur is effected by flexing the leg and 
thigh and bringing the limb into a position of abduction; 
it is then adducted and rotated inward in a broad sweep 
across the abdomen and brought down to its natural posi- 
tion, and the head of the bone slips into the acetabulum 
(Fig. 320). 

In making these manipulations the head of the bone 
sometimes slips back upon the dorsum of the ilium, con- 
verting the downward dislocation into a posterior one; if 



DISLOCATIONS OF THE HIP. 

Fig. 



407 




Downward and forward dislocation of femur. (Cooper.) 



Fig. 320. 




Reduction of downward and forward dislocation of femur. (Bigelow.) 



408 



DISLOCATIONS. 



this accident occurs the displacement should be remedied 
by making the manipulations appropriate for the reduction 
of the letter dislocation. 

Upward and Forward Dislocation of the Head of the Femur. 
In this variety of dislocation the head of the bone rests 
upon the pubis; this form of displacement is also spoken 
of as a pubic dislocation (Fig. 321). 

Fig. 321. 




Forward and upward dislocation of the femur. (Cooper. 



The reduction of forward and upward dislocations of 
the head of the femur is effected by much the same manip- 
ulation as is employed in the reduction of downward and 
forward dislocations, except that in the pubic dislocation 
the flexed limb should be carried across the sound thigh 



DISLOCATIONS OF THE HIP. 



409 



at a higher point. The thigh being flexed the head of the 
bone is drawn down from the pubis; it is then semi- 
abducted and rotated inward to disengage the bone com- 
pletely. While rotating inward and drawing on the thigh 



Fig. 322. 




Outward dislocation of the patella. (Duplay.) 

the knee should be carried inward and downward to its 
place by the side of its fellow, and the head of the bone 
will usually slip into the acetabulum. 

As before stated, various anomalous displacements of the 
head of the femur- occasionally occur; the head of the bone 
may pass directly upward or downward between the sci- 
atic notch and thyroid foramen, or downward and back- 
ward on the body of the ischium, or downward and 
backward into the lesser sciatic notch, or downward, in- 
ward, and forward into the perineum. These anomalous 
displacements usually occur where there has been exten- 
sive laceration of the capsular and Y- ligaments. 



410 DISLOCATIONS. 

The dressing of cases after redaction of dislocations of 
the head of the femur consists in keeping the patient at 
rest in bed upon his back, and the limb should be kept at 
rest by sand-bags applied to either side of the limb, or the 
knees should be tied together. 

The patient should be kept at rest for two or three 
weeks, and at the end of this time may be allowed to get 
out of bed and go about on crutches. 

Dislocations of the Patella. The patella may be dis- 
located outward, inward, or upward, or it may be rotated 
upon its own axis. The outward dislocation is the dis- 
placement most usually seen (Fig. 322). 

Upward dislocation of the patella can only result from 
laceration of the ligamentum patella?, and the treatment 
in such cases is similar to that for fracture of the patella. 

The reduction of dislocations of the patella is effected 
by extending the leg upon the thigh and flexing the thigh 
upon the pelvis, to relax the quadriceps femoris muscle, 
when the patella can usually be forced back into place; in 
some cases alternate flexion and extension of the leg will 
accomplish the same result. 

The dressing after reduction of the displacement consists 
in the application of a posterior straight splint or a moulded 
binder's board or felt splint to keep the joint at rest; the 
splint should be worn for a week or ten days. 




External condyle of femur 
Forward dislocation of the knee. (Bryant.) 

Dislocations of the Knee. The head of the tibia may 
be dislocated forward, backward, or laterally ; the latter 
dislocations are always incomplete, forward dislocation 



DISLOCATIONS OF THE FIBULA. 411 

being the variety of displacement most commonly met with 
(Fig. 323). 

The reduction of dislocations of the knee is effected by 
extension and counter-extension with forced flexion of the 
knee with pressure, aided by rocking movements. The 
treatment of cases of dislocation of the knee after reduc- 
tion consists in fixing the knee-joint by the application of 
a straight posterior splint or a moulded splint of binder's 
board. As there is usually marked swelling following 
these injuries from violence to the joint structures, the 
application of evaporating lotions for a few days will be 
found useful. As soon as the swelling has subsided the 
joint should be put up in a plaster-of-Paris dressing, and 
this should be retained for four weeks. 

Dislocation of the Semilunar Cartilages. The dis- 
placement here consists in the slipping forward or back- 
ward and wedging of the semilunar cartilages between the 
femoral condyles and the tibia. 

Reduction of the displaced cartilages can usually be 
effected by hyperflexion of the knee, followed by sudden full 
extension, or by alternately flexing and extending the joint. 
Excision of the displaced cartilages is sometimes required 
in cases in which they cannot be reduced by manipulation. 

The dressing of these cases after reduction of the dis- 
placed cartilages consists in the application of a posterior 
straight splint or a plaster-of-Paris dressing to fix the knee- 
joint; the splint should be worn for three or four weeks, 
and if there is a tendency to redisplacement the patient 
should wear a knee-cap of leather or muslin, to partially 
fix the joint, with compresses so arranged as to make press- 
ure upon the edge of the joint. 

Dislocations of the Fibula. Dislocations of the fibula 
may occur at either of its extremities, and the direction of 
the displacement may be forward, backward, or upward ; 
dislocation of the head or upper extremity of the fibula 
being the most common, although all are rare forms of 
displacement. 

The reduction of dislocations of the head of the fibula 
is effected by flexing the leg upon the thigh and making 



412 



DISLOCATIONS. 



direct pressure and extension. Dislocations of the lower 
extremity of the fibula are reduced by manipulation and 
pressure. The dressing of cases after reduction of dislo- 
cations of the fibula consists in the application of a com- 
press and moulded binder's board splint, and the dressing 
should be retained for three or four weeks. 

Dislocations of the Ankle. Dislocations of the foot 
upon the bones of the leg results from the separation of 
the articular surface of the astragalus from that of the 
tibia and fibula, and the displacement may be forward, 
backward (Fig. 324), or lateral (Fig. 325), the latter vari- 
ety being often associated with fractures of the malleoli. 



Fig. 324. 



Fig. 325. 





Dislocation of foot backward. 
(Bryant.) 



Dislocation of foot inward. 
(Bryant.) 



The reduction of dislocations of the ankle is effected by 
traction, combined with flexion and rotation of the ankle- 
joint, the leg being first flexed upon the thigh to relax the 
tendo-Achillis, and in some cases the subcutaneous division 
of this tendon is required before the reduction can be satis- 
factorily accomplished. 

The dressing of dislocations of the ankle after reduction 
consists in the application of a fracture-box or of paste- 
board splints, to fix the ankle, care being taken to see that 



DISLOCATIONS OF THE TARSAL BONES. 413 

the foot is fixed at a right angle to the leg, and in the 
application of evaporating lotions for a few days; after 
the swelling has subsided a plaster-of-Paris dressing should 
be applied and retained for three or four weeks. 

Dislocations of the Tarsal Bones. The astragalus may 
be dislocated from the bones of the leg and from the other 
tarsal bones, being thrust forward, backward, outward (Fig. 
326), or inward. The reduction of dislocations of the as- 

FlG. 326. 




Dislocation of astragalus outward. (Hamilton.) 



tragalus outward is effected by first flexing the leg upon 
the thigh and making extension from the foot and rotat- 
ing it at the same time, direct pressure being made upon 
the displaced bone; in some cases subcutaneous section of 
the tendo-Achillis has assisted materially in the reduction 
of the displaced bone. Backward dislocation of the astrag- 
alus is usually irreducible; the patient, however, in many 
cases recovers with a useful foot. In cases of irreducible 



414 DISLOCATIONS. 

dislocations of the astragalus, excision of the atragalus 
may ultimately be required. 

After the reduction of dislocations of the atragalus, the 
foot and leg should be put at rest in a fracture-box, or by 
means of moulded splints of pasteboard or felt; evaporat- 
ing lotions should also be employed over the region of the 
injury for a few days, and when the swelling has subsided 
a plaster-of-Paris dressing should be applied and retained 
for three or four weeks. 

Dislocations of the calcaneum and scaphoid upon the 
astragalus, or of the calcaneum upon the astragalus and 
cuboid, or upon the astragalus alone; of the scaphoid and 
cuboid upon the calcis and astragalus ; or of the cuboid, 
scaphoid, or cuneiform bones, are occasionally met with. 

Their reduction is effected by traction and direct press- 
ure, and after this has been accomplished the parts should 
be put at rest by the application of a splint and compresses. 

Dislocations of the Metatarsal Bones and Phalanges 
of the Toes. These dislocations usually result from 
crushing forces which destroy the vitality of the soft parts 
so completely that amputation is required. Their reduc- 
tion in cases of simple or uncomplicated dislocations is 
effected by traction, manipulation, and pressure. After 
reduction of the displacement the parts should be kept in 
position by the application of splints, compresses, and 
bandages. 

Old Dislocations. 

The reduction of old dislocations is attended with more 
difficulty and danger than that of recent dislocations, due 
to the permanent contraction and structural changes which 
occur in the muscles and to the adhesions which form 
between the displaced bone and the parts with which it is 
in contact. The reduction of old dislocations can usually 
be accomplished by the manipulations appropriate for re- 
cent dislocations of the same variety; but occasionally the 
use of more forcible extension is required, which is made 
by bands and pulleys (Fig. 327) or by vertical extension 
(Fig. 328). The first step in the reduction of old dislo- 



OLD DISLOCATIONS. 
Fig. 327. 



415 




Reduction of old dislocation of the femur by pulleys. (Cooper.) 
Fig. 328. 




Reduction of old dislocation of hip by vertical extension. (Bigelow.) 



416 DISLOCATIONS. 

cations consists in thoroughly breaking up the adhesions 
which have been formed between the displaced bone and 
the surrounding tissues; this has, in some cases, resulted 
in the laceration of muscles, nerves, and bloodvessels, 
and in the fracture of the displaced bones or neigh- 
boring bones, so that the manipulations should be made 
with the least force that will accomplish the object desired. 
After the reduction of old dislocations, difficulty is some- 
times experienced in maintaining the bone in its proper 
place, due to the changes which have occurred in the artic- 
ular surfaces. 

Compound Dislocations. 

These are always grave injuries, and amputation or 
excision may be required. At the present time, under the 
modern methods of wound treatment, operative measures 
are not often required. The reduction is effected in the 
same manner as in simple dislocations of corresponding 
parts, the greatest care being taken to render the wound 
aseptic, and to keep it in this condition by the application 
of a full antiseptic dressing. After reducing the disloca- 
tion and dressing the wound some form of fixation splint 
should be applied, to fix the joint for a short time. 

Complicated Dislocations. 

In dislocations complicated by fracture near the seat of 
displacement, the displaced bone should, if possible, be 
first reduced, and this in many cases is a matter of much 
difficulty, as the fracture prevents the surgeon from using 
leverage otherwise present, in the reduction, and he has 
often to depend entirely upon pressure and manipulation 
to overcome the displacement. 

After reduction of the dislocation the fracture should 
be reduced and dressed. 

Dislocation complicated by rupture of the main artery 
of the limb may require, after reduction of the displace- 
ment, exposure and ligation of the vessel or amputation 
of the limb. Kupture of an important nerve trunk com- 



PATHOLOGICAL DISLOCATIONS. 417 

plicating a dislocation may call for subsequent exposure 
and suturing of the divided nerve. 

Spontaneous, Pathological, and Congenital Dislocations. 

In the treatment of these varieties of dislocations after 
the reduction of the displacement by manipulation and 
pressure, much difficulty is often experienced in maintain- 
ing the reduction. To effect the latter object the use of 
splints and bandages is employed, and also the use of many 
ingenious forms of apparatus adapted to particular dislo- 
cations. 

Tenotomy or myotomy is often required to prevent re- 
currence of the deformity, and continuous extension is 
also of much value in the treatment of these displace- 
ments. 



27 



PAET V. 

OPERATIONS 



In view of the fact that at the present time in our 
medical schools much more attention is paid to practical 
surgery — that is, operative procedures upon the cadaver 
— it has been thought advisable to introduce a very brief 
description of a number of operations which can with 
advantage be performed upon the cadaver. Too much 
value cannot be attached to the importance of the student 
rendering himself familiar with the use of instruments 
aud their manipulation in the various operative proced- 
ures, and also familiarizing himself with the appearance 
of the anatomical parts exposed in operations. The intro- 
duction of sutures, the application of ligatures, the closing 
of wounds, the cutting and fitting of flaps in plastic oper- 
ations, are procedures the practical value of which to the 
student cannot be overestimated. 



LIGATION OF ARTERIES 

In the application of a ligature to an artery in its con- 
tinuity the surgeon should make his incision in the line 
which corresponds to the general course of the vessel, and 
he should be thoroughly familiar with the anatomy and 
with the surgical landmarks of the part. A portion of 
the artery, when possible, should be selected for the appli- 
cation of the ligature half an inch or an inch from any 
large collateral branch. The position of the incision being 



LIGATION OF ARTERIES. 419 

selected, the surgeon steadies the skin with two fingers and 
makes an incision of the required length through it with 
a scalpel; the superficial fascia is next picked up on a 
director, any large superficial veins which come into view 
being displaced, and divided to an equal length with the 
incision in the skin; the deep fascia being exposed, it 
should be nicked and divided upon a director; the inter- 
muscular space, or the edge of the muscle or muscles which 
are the guide to the vessel, should next be sought for, and 
small arteries coming from the main vessel through these 
spaces will often serve as valuable guides to the position of 
the artery. The surgeon next separates the tissues with the 
director, handle of the knife, or the finger until the sheath 
of the vessel is exposed; this is recognized by its commu- 
nicated pulsation and by the absence of the smooth, shin- 
ing surface and pinkish-white color which the surface of 
the artery presents. The sheath of the artery should be 
picked up with forceps and nicked with the point of the 
knife applied flatwise (Fig. 329 A); the incision into the 
sheath should be very limited, only large enough to allow 
the aneurism needle to pass through it around the vessel; 
extensive dissections or separations of the sheath from the 
artery should be avoided, as the nutrition of the artery at 
the point of ligature may thus be impaired, and sloughing 
and secondary hemorrhage may result. A distinct sheath 
is found only about the main arterial trunks, which is 
replaced in the smaller arteries by a layer of loose cellular 
tissue. The wall of the artery being exposed, an aneurism 
needle (Fig. 330) is passed around the vessel, threaded 
with a catgut ligature, and withdrawn (Fig. 329 JB); the 
needle may be threaded before being passed, in which 
case the ligature is grasped with forceps and drawn 
through while the needle is withdrawn. The best ma- 
terial for ligatures is silk or carefully prepared chromi- 
cized catgut. The needle should be passed away from 
important structures, such as accompanying veins and 
nerves. 

Before the ligature is tied the surgeon should satisfy 
himself that the ligature when tied will control the circu- 



420 



OPERATIONS. 



lation in the artery below its point of application, by 
placing the tip of his finger upon the vessel and drawing 
upon the ends of the ligature, so as to occlude the vessel 
at the point of application. Being satisfied as to this 
point, the ligature is tied with a reef-knot, or a surgeon's 
knot and reef-knot combined, and the ends of the ligature 
are cut short in the wound (Fig. 329 C). 



Fig. 329. 



Fig. 330. 





A. Opening sheath ; b. Passing ligature around the 
vessel ; c. Tying the artery. (Bryant.) 



Aneurism needle. 



Some authorities recommend the application of two liga- 
tures a short distance apart in the ligation of vessels in 
their continuity, and a division of the vessel between 
them, so that both ends can retract into the cellular 
sheath. 

Ligation of Special Arteries. 

Ligation of the Innominate Artery. The innominate 
artery lies immediately behind the sterno-clavicular artic- 
ulation, and is in relation in front with the innominate 



LIGATION OF THE INNOMINATE ARTERY. 421 

veins and pneumogastric nerve, on the inner side with the 
trachea, on the outer side and behind with the pleura. 

The incision is a V-shaped incision, each branch of 
which is two and a half or three inches in length, one of 
which lies over the anterior edge of the sterno-cleido- 
mastoid muscle and the other parallel to and a little above 
the clavicle (Fig. 331, A). The incisions are carried down 
to the superficial fascia and a flap is dissected up. If the 
anterior jugular vein is met with it should be displaced. 

Fig. 331. 




Line of incision ior—A, innominate artery ; B, right subclavian artery ; C, left 
subclavian artery ; D, vertebral or inferior thyroid artery ; E, axillary artery 
below clavicle. (Stimson.) 

The sternal and clavicular attachments of the sterno- 
cleido-mastoid are next divided upon a director half an 
inch above the bone. The sterno-thyroid and sterno- 
hyoid muscles and the middle cervical fascia are then ex- 
posed, covered by the thyroid veins. The outer fibres of 
the sterno-hyoid and sterno-thyroid muscles are next 
divided, the thyroid vein being held aside, when upon 
tearing through the fascia with a director the common 
carotid artery is exposed and traced down to the innomi- 
nate artery; the innominate veins are pressed against the 
sternum with the finger, and the artery is separated from 



422 OPERATIONS. 

its sheath about half an inch below its bifurcation, and the 
aneurism needle is passed around the vessel from the outer 
side, so as to avoid the vein, pneumogastric nerve, and 
pleura. 

Ligation of the Subclavian Artery. This artery may 
be tied at three points; in its first portion, between the 
trachea and scaleni muscles; in its second portion, behind 
the scaleni muscles; and in its third portion, external to 
the scaleni muscles. 

The left subclavian artery in its first portion is larger 
and more vertical in its direction than the right subclavian, 
and is situated more posteriorly. From the difficulty in ex- 
posing this portion, and from the possibility of injuring 
the thoracic duct, the ligation of this artery in its first 
portion has been seldom attempted. 

The incision for the first portion of the subclavian artery 
is the same as that for the innominate (Fig. 331, A), and 
the ligature is passed from the outer side, the pneumogas- 
tric and phrenic nerves being pressed inward toward the 
carotid artery. 

The right and left subclavian arteries are also seldom 
tied in their second portions — that is, behind the scaleni 
muscles — but are frequently tied in their third portions — 
that is, external to the scaleni muscles. 

The incision for the second portion of the subclavian 
artery begins an inch external to the sterno-clavicular 
articulation, half an inch above and parallel to the clav- 
icle, and is three or four inches in length (Fig. 331, B or 
C). The steps of the operation are the same as for liga- 
tion of the third portion, and when the scalenus anticus 
muscle has been exposed it is divided upon a director; the 
phrenic nerve which lies upon its anterior aspect is to be 
avoided. 

The incision for the third portion of the subclavian artery 
is the same as for the second portion (Fig. 331, B or C). 
The skin and platysma being divided, the external jugular 
vein is exposed and drawn to one side or divided between 
two ligatures; the superficial fascia is next divided upon a 
director; the posterior belly of the omo-hyoid muscle is 



LIGATION OF THE VERTEBRAL ARTERY. 423 

next fouud and drawn upward and outward; the outer 
border of the scalenus actions is cext felt for aod followed 
down to the tubercle of the first rib — the artery lies against 
this, between it aod the lowest bundle of the brachial 
plexus. The artery is next denuded with the director, 
and the needle is passed from below, care being taken not 
to include the lowest bundle of the brachial plexus in the 
ligature (Fig. 332). 

Fig. 332. 




Ligation of subclavian and lingual arteries. (Bryant.) 



Ligation of the Vertebral Artery. The incision for 
the ligation of the vertebral artery is three or three and a 
half inches in length, parallel with the anterior edge of 
the sterno-cleido-mastoid muscle, ecdiog ac icch above 



424 OPERATIONS. 

the clavicle (Fig. 331, D). The anterior edge of the 
sterno-cleido-mastoid being exposed, the middle cervical 
fascia is divided and the carotid artery and jugular vein 
are exposed and drawn inward. The gap between the 
longus colli muscle and the scalenus anticus muscle is 
next felt for about an inch below the carotid tubercle; the 
fascia covering it is next torn through and the muscles are 
separated and the vertebral vein comes into view. When 
this vein is held aside the vertebral artery is exposed, and 
the ligature is then passed around it. 

Ligation of the Inferior Thyroid Artery. The in- 
cision for the iuierior thyroid artery is the same as that for 
the vertebral artery (Fig. 331, D.) The anterior edge of 
the sterno-cleido-mastoid muscle being exposed, it is drawn 
outward, the middle cervical fascia is next divided, and the 
carotid artery and internal jugular vein are drawn outward 
with a retractor. The head being flexed slightly, the sur- 
geon feels for the carotid tubercle, and then separates the 
cellular tissue with a director, and the artery should be 
found below the carotid tubercle. The needle should be 
passed between the artery and vein. 

Ligation of the Internal Mammary Artery. The 
incision, a vertical one, two and a half inches in length, 
commences at the lower border of the clavicle, parallel 
with and three lines external to the margin of the ster- 
num. Divide the skin and superficial fascia and expose 
the fibres of the great pectoral muscle, the external inter- 
costal aponeurosis, and the muscular fibres of the internal 
intercostal muscle. Raise the fasciculi of the latter muscle 
upon a director and divide them, and the vessel will be 
exposed. 

The internal mammary artery is not often tied below 
the fourth intercostal space. 

Ligation of the Common Carotid Artery. The point 
of election for the ligation of the common carotid artery 
is just above the omo-hyoid muscle, about three-quarters 
of an inch below the bifurcation of the vessel, which takes 
place at a point on a line with the upper border of the 
thyroid cartilage. 



LIGATION OF COMMON CAROTID ARTERY. 425 

The incision for the common carotid artery is three 
inches in length along the anterior border of the sterno- 

FlG. 333. 




Line of incision for common carotid artery at point of election. (Stimson.) 
Fig. 334. 




Relations of the left common carotid artery above the omo-hyoid muscle. 

(ESMARCH.) 



426 



OPERA TIONS. 



cleido-mastoid muscle, the centre of which corresponds 
with the crico-thyroid space (Fig. 333). 

Divide the skin, platysma, cellular tissue, and aponeu- 
rosis, avoiding the superficial veins, and expose the ante- 
rior edge of the sterno-cleido-mastoid ; seek for the inter- 
space between this muscle and the sterno-hyoid and 
sterno-thyroid muscles, draw the latter muscles inward, 
and the artery will be exposed with the jugular vein exter- 
nal to it; the descendens noni nerve lying upon its sheath 
should be displaced outward. The sheath is next picked 
up and opened and the artery is separated from it with 
a director; the artery lies internally, the internal jugu- 
lar vein externally and somewhat more superficial, and 
the pneumogastric nerve lies between the two, and is more 
deeply placed. The sympathetic nerve is posterior to the 
vessel external to the sheath. The needle is passed from 
without inward, care being taken to avoid injury of the 
vein and nerve (Fig. 334). 

Fig. 335. 




JT 



Line of incision for— A, lingual artery ; B, external and internal carotid arteries; 
C, occipital artery ; D, temporal artery ; E, facial artery. (Stimson.) 

Ligation of the External Carotid Artery. The in- 
cision for the ligation of the external carotid artery is over 



LIGATION OF THE LINGUAL ARTERY. 427 

the inner edge of the sterno-cleido-mastoid muscle from 
the angle of the jaw to a point corresponding to the middle 
of the thyroid cartilage (Fig. 335, B). The skin, pla- 
tysma, and cellular tissue being divided, the external jug- 
ular vein is drawn aside when encountered; the deep fascia 
being opened, the facial and lingual veins will be exposed, 
which should be drawn to one side; the artery is next 
exposed, covered by the hypoglossal nerve and the stylo- 
hyoid and digastric muscles. The vessel should next be 
isolated from the internal carotid artery and internal jug- 
ular vein, both of which lie along its outer side. The 
needle should be passed from without inward. 

Ligation of the Internal Carotid Artery. The in- 
cision is the same as for the external carotid artery (Fig. 
335, JB); the vessel is external to the external carotid 
artery, and in passing the needle the point should be 
directed away from the internal jugular vein — that is, 
from without inward. 

Ligation of the Superior Thyroid Artery. The in- 
cision is about three inches in length along the anterior 
border of the sterno-cleido-mastoid muscle, starting a little 
lower down than that for the external carotid artery. The 
skin, superficial fascia, platysma, and deep fascia being 
divided, the cellular tissue in the sulcus between the upper 
portion of the larynx and the great vessels of the neck 
should be broken up with the director and the vessel ex- 
posed. The needle should be passed around the vessel 
from above downward. 

Ligation of the Lingual Artery. The incision is a curved 
one two inches long, its concavity directed upward from 
the anterior edge of the sterno-cleido-mastoid muscle, half 
an inch above the great horn of the hyoid bone, to a point 
one inch within the median line of the neck (Fig. 335, A). 
Divide the skin and platysma, displacing the superficial 
veins, and open the deep fascia, when the submaxillary 
gland will be exposed; this is displaced upward with the 
handle of the knife and the tendon of the digastric muscle 
attached to the hyoid bone, and the hypoglossal nerve 
will be exposed; next divide the fibres of the hyoglossus 



428 OPERATIONS. 

muscle midway between the hypoglossal nerve and the 
hyoid bone, and the lingual artery will be exposed (Fig. 
336). 

Fig. 336. 




Relations of the lingual artery. (Esmarch.) 

The needle should be passed around the vessel from 
above downward, in order to avoid the nerve. 

Ligation of the Facial Artery. The facial artery 
passes over the inferior maxilla just in front of the ante- 
rior edge of the masseter muscle, and is accompanied by 
the facial vein, which lies nearer to the muscle. 

The incision is either a horizontal one along the lower 
border of the maxilla or a vertical one an inch in length 
(Fig. 335, E). The skin, subcutaneous tissue, and fascia 
being divided, the artery is exposed and the needle should 
be passed around the vessel away from the vein. 

Ligation of the Occipital Artery. The incision is two 
inches in length, starting from a point half an inch below 
and in front of the apex of the mastoid process, and carried 
obliquely backward, parallel to the border of this process 
(Fig. 335, C). Divide the skin and fascia and expose the 
insertion of the sterno-cleido-mastoid muscle, which is also 
divided, and the aponeurosis of the splenius is exposed; 
this is also opened and the digastric groove is felt for, and 
when the belly of the digastric muscle is exposed the artery 



LIGATION OF THE AXILLARY ARTERY. 429 

is brought into view by separating the cellular tissue in the 
anterior angle of the wound with a director (Fig. 337). 

Ligation of the Temporal Artery. The incision is a 
transverse one, one inch in length, starting from the tragus 
of the ear forward over the zygomatic arch (Fig. 335, D), 
or a vertical one of the same length a little in front of the 
tragus of the ear. 

Divide the skin and expose the subcutaneous cellular 
tissue, whch in this region is very dense and fibrous. 
This tissue should be broken up with a director, and the 
artery should be found in it about a quarter of an inch in 
front of the ear (Fig. 338). The temporal vein accom- 



FlG. 337. 



Fig. 338. 





Ligation of the occipital artery. 
(Skey.) 



Ligation of the temporal artery. 
(Skey.) 



panies the artery and lies nearer to the ear, and in some 
cases the auriculo-temporal nerve is in close relation to 
the artery. The needle should be passed from behind 
forward. 

Ligation of the Axillary Artery. The axillary artery 
extends from the middle of the clavicle to the insertion of 
the teres major into the humerus; the axillary vein lies 
upon the inner side and in front of the artery. The axil- 
lary artery is tied either in its upper portion, just below 
the clavicle, or at its lower portion in the axilla. 



430 OPERATIONS. 

Axillary Artery Below the Clavicle. The incision is four 
inches in length from the summit of the coracoid process 
inward a short distance below the clavicle (Fig. 331, E), 
or an incision three inches in length, commencing at a 
point one-half an inch from the sterno-clavicular articu- 
lation, and carried obliquely downward toward the axilla. 

The skin and subcutaneous tissue having been divided 
the deep fascia is exposed and opened, and the axillary 
artery may be reached by following the intermuscular 
space between the sternal and clavicular fibres of the pec- 
toralis major which leads upward toward the clavicle and 
to the pectoralis minor; or the fibres of the pectoralis 
major being exposed are cut through and the costo-cora- 
coid membrane is next torn through with a director, care 
being taken to avoid injury of the cephalic vein at the 
outer portion of the wound; the pectoralis minor is now 
seen, and after separating the cellular tissue with a director 
the axillary vein is seen crossing from the upper edge of 
the muscle to the clavicle; the vein almost completely 
covers the artery, which is exposed by drawing the vein 
inward. The needle is passed around the artery from 
within outward. 

Axillary Artery in the Axilla. The incision is two and a 
half inches long, started at the upper part of the axilla 

Fig. 339. 



A 

A. Incision for axillary artery in axilla. B. Incision for brachial artery. 

(Stimson.) 

and carried down the arm at the edge of the coraco- 
brachialis muscle (Fig. 339, A). The skin only is divided 



LIGATION OF THE AXILLARY ARTERY. 



431 



in the first incision. The deep fascia is then picked up 
and divided upon a director. As soon as the fibres of the 



Fig. 340. 




Relations of right axillary artery in axilla. (Esmarch.) 
Fig. 341. 




Relations of right brachial artery at middle of arm. (Esmarch.) 

inner border of the coraco-brachialis muscle are exposed 
and held aside by a retractor, the operator will see the 



432 OPERATIONS. 

median nerve, the musculo-cutaneous nerve, and the axil- 
lary artery. To the inner side of the artery are the axil- 
lary vein, ulnar and internal cutaneous nerves (Fig. 340). 
The needle should be passed around the artery from the 
vein toward the coraco-brachialis muscle. 

Ligation of the Brachial Artery. The incision is 
three inches long at the middle of the arm, on a line corre- 
sponding to the inner edge of the biceps muscle (Fig. 
351, B). The skin and cellular tissue having been divided, 
care being taken not to injure the basilic vein, which should 
be drawn posteriorly, the deep fascia is next cut through 
and the fibres of the biceps muscle are exposed (Fig. 341); 
this muscle should be drawn forward and the sheath of 
the vessels enclosing the artery, veins, and median nerve 
exposed; the sheath having been opened, the median nerve 
is pressed aside and the artery is separated from its veins, 
and the needle is passed from the side of the nerve around 
the vessel. 

In ligating the brachial artery the occasional high divis- 
ion of the vessel must be borne in mind. 

Brachial Artery at Bend of the Elbow. The incision is 
two inches in length, along the inner border of the tendon 

Fig. 342. 

Tendinous aponeurosis 

divided. 




Ligation of the brachial artery at the bend of the elbow. (Bryant.) 

of the biceps muscle. Divide the skin, superficial fascia, 
and the bicipital aponeurosis, under which the artery will 
be exposed, resting upon the brachialis anticus muscle 



LIGATION OF THE RADIAL ARTERY. 



433 



(Fig. 342). The median nerve is to the inner side and 
some distance from the artery. The needle should be 
passed around the vessel, after isolating the veins, from 
within outward. 

Ligation of the Radial Artery. The radial artery 
extends in a straight line from a point half an inch below 
the centre of the fold of the elbow to the inner side of the 
styloid process of the radius. 



Fig. 343. 



Fig. 344. 





Relations of right radial artery in 
the upper third of the forearm. 
(Esmakch.) 

Fig. 345. 




Line of incision for— A. Radial artery 
in upper third. B. Radial artery in 
lower third. C. Ulnar artery in upper 
third. D. Ulnar artery in lower third. Relations of right radial artery ahove 
(Stimson.) the wrist. (Esmarch.) 

The radial artery may be tied at its upper, middle, or 
lower third, or at the root of the thumb. 

28 



434 OPERATIONS. 

Radial Artery in the Upper Third of the Forearm. The 
incision for the radial artery at its upper third is two 
and a half inches in length on a line drawn from the 
middle of the bend of the elbow to the ulnar side of the 
styloid process of the radius; the incision should begin 
one and a half inches below the bend of the elbow (Fig. 
343, A). Divide the skin and superficial fascia, avoiding 
the superficial veins. When the deep fascia is exposed, 
find the edge of the supinator longus muscle and divide 
the aponeurosis along its ulnar side, and expose the fibres 
of the pronator radii teres muscle. The vessel lies in the 
interspace between these muscles surrounded by adipose 
tissue, and upon being exposed the veins should be isolated 
and the needle passed from without inward. The radial 
nerve lies so far external to the artery that it is not often 
exposed in the operation (Fig. 344). 

Radial Artery in the Middle Third of the Forearm. The 
incision is two inches in length, following the same line as 
that for the upper third of the artery. After dividing 
the skin, superficial and deep fascia, the artery is found 
in the interspace between the flexor carpi radialis on the 
inner side and the supinator longus on the outer side; 
the radial nerve at this part of the arm is in close relation 
with the vessel to the radial side, and the needle should 
be passed around the artery from without inward. 

Radial Artery in the Lower Third of the Forearm. The 
incision is two inches in length, following the same line 
(Fig. 343, B), ending one inch above the wrist. The 
skin, superficial and deep fascia being divided, the artery 
will be found between the tendon of the flexor carpi 
radialis on the inner side and the tendon of the supinator 
longus on the outer side (Fig. 345). The veins being 
separated the needle may be passed in either direction. 

Radial Artery at the Root of the Thumb. The radial 
artery may also be tied at the root of the thumb. 

The incision is one inch in length between the tendons 
of the extensor ossis metacarpi pollicis and extensor primi 
internodii pollicis on the outer side, and the tendon of the 
extensor secundi internodii pollicis on the inner side. The 



LIGATION OF THE ULNAR ARTERY. 



435 



skin and superficial fascia being divided and the radial 
vein being displaced, the deep fascia is opened and the 
artery is exposed at the bottom of the wound; the needle 
may be passed in either direction. 

Ligation of the Ulnar Artery. The ulnar artery is 
tied at the junction of the upper and middle third of the 
forearm and at the lower third. 

Ulnar Artery at the Junction of the Upper and Middle 
Thirds of the Forearm. The incision is three inches in 
length, starting four inches below the internal condyle of 
the humerus, on a line passing from the internal condyle 
of the humerus to the outer border of the pisiform bone 
(Fig. 343, C). Divide the skin and superficial fascia, 
and when the deep fascia has been exposed and the in- 
terspace between the flexor carpi ulnaris and the flexor 
sublimis digitorum appears, enter this interspace and raise 



Fig. 346. 




Relations of the right ulnar artery at upper third of the forearm. (Esmaech.) 



the flexor sublimis digitorum and work transversely across 
the arm. The artery will be found resting upon the deep 
flexor, with the ulnar nerve to the ulnar side. The needle 
should be passed from the nerve around the artery (Fig. 
346). 

Ulnar Artery in the Lower Third of the Forearm. The 
incision is two inches in leugth, a little to the radial side 



436 OPERATIONS. 

of the tendon of the flexor carpi ulnaris, which is attached 
to the pisiform bone, ending an inch above the wrist (Fig. 
343, D). Divide the skin and superficial fascia and open 
the deep fascia, and the artery will be exposed, with its 
accompanying veins, between the tendons of the flexor 
carpi ulnaris and flexor sublimis digitorum, the ulnar 
nerve being to the ulnar side of the vessel. The needle 
should be passed from within outward to avoid the nerve 
(Fig. 347). 

Fig. 347. 




Relations of right ulnar artery above the wrist. (Esmarch.) 

Ligation of the Interosseous Artery. The incision is 
similar to that employed in the ligation of the ulnar artery 
in its upper third. 

Ligation of the Abdominal Aorta. The incision is in 
the linea alba from a point three inches above the umbili- 
cus to a point three inches below it. The superficial 
structures being divided, the peritoneum is opened upon a 
director, and the intestines are pressed aside and the aorta 
is exposed, covered by peritoneum, with the filaments of 
the sympathetic nerve resting upon it and the vena cava 
to the right side. Tear through the peritoneum and pass 
the needle from right to left around the vessel. After 
tying the ligature the ends should be cut short and the 
external wound should be closed as in the ordinary cceli- 
otomy wound. 

The vessel may also be exposed by an incision along 
the anterior border of the quadratus lumborum muscle, 
from the last rib to the crest of the ilium. The skin, 
lumbar muscles, and fascia transversalis being divided, 



LIGATION OF THE COMMON ILIAC ARTERY. 437 

the wound is held open with blunt hooks, so that the 
retro-peritoneal space is exposed and the aorta brought 
into view. The vessel being separated from the vena 
cava and nerves, the needle is passed around it and the 
ligature applied. 

Ligation of the Common Iliac Artery. The aorta 
divides into the two common iliac arteries on the left 
side of the fourth lumbar vertebra, and these arteries are 
usually about two inches in length, and bifurcate opposite 
the sacroiliac synchondrosis to form the internal and 
external iliac arteries; the length of the common iliac 
artery, however, may vary considerably, being three or 
four inches in length in some cases. 

Fig. 348. 




Line of incision for— A. Common iliac artery. B. External iliac artery. 
C. Femoral artery in Scarpa's triangle. (Stimson.) 

The incision for ligation of the common iliac artery is 
four to six inches in length, beginning one-half inch above 
the middle of Poupart's ligament, and is carried outward, 
curving upward after passing the anterior superior spine 
of the ilium (Fig. 348, A). 

Divide the skin, superficial fascia, and aponeurosis of 
the external oblique muscle, and then divide the fibres 
of the internal oblique and trans versalis muscles upon a 
director and expose the transversalis fascia. This is 



438 



OPERATIONS. 



opened at the lower part of the wound, and the finger 
is introduced and the peritoneum is pressed back; the 
opening in the transversalis fascia is next enlarged, and 
the peritoneum is carefully drawn inward and upward 
with the fingers toward the inner edge of the wound. 
The operator next feels for the external iliac artery, and 
passes the finger along this until the common iliac artery 
is reached. The loose cellular tissue in which it is em- 
bedded is next separated, and the needle is passed from 
within outward, to avoid the common iliac vein (Fig. 
349), which on the left side lies on the inner side of the 

Fig. 349. 




Ligation of the common iliac artery. (Liston.) 

artery, and on the right side lies behind the artery. The 
ureter generally remains attached to the peritoneum; if 
not, it is seen crossing the bifurcation of the common iliac 
with the geni to-crural nerve, and care should be taken to 
avoid injurv of these structures if present. 

Transperitoneal Method. The common iliac artery may 
also be exposed and tied by an incision made over the 



LIGATION OF THE EXTERNAL ILIAC ARTERY. 439 

artery through the abdominal wall opening the peritoneal 
cavity; the vessel being tied, the ends of the ligature are 
cut short, and the external wound is closed in the same 
manner as that resulting from the exposure of the abdom- 
inal aorta by incision through the peritoneum. 

Ligation of the Internal Iliac Artery. The incision 
is in the same line as for the common iliac artery, but it 
need not be quite so long (Fig. 348, A). The peritoneum 
being exposed, it is pushed upward and inward, and the 
internal iliac artery is exposed. The vessel is carefully 
isolated from the vein, which lies behind and on the inner 
side, and the needle is passed from within outward. 

The transperitoneal method may also be employed in 
exposing; and ligating this vessel. 

Ligation of the External Iliac Artery. The incision 
is three or four inches in length, half an inch above the 




Relations of the right external iliac artery. (Esmabch. 



middle of Poupart's ligament, made at first parallel to it 
and then curved upward (Fig. 348, B). The tissues of the 
abdominal wall being divided and the peritoneum exposed ; 



440 



OPERATIONS. 



it is pushed upward and inward in the same manner as 
for exposure of the common iliac artery. The artery lies 
at the inner border of the psoas muscle, the vein on its 
inner side and the anterior crural nerve covered by the 
iliac fascia on the outer side; the genito-crural nerve passes 
obliquely across the artery (Fig. 350). The needle should 
be passed from within outward. 

The transperitoneal method may also be employed in 
ligating this vessel. 

Ligation of the Gluteal Artery. The incision is three 
or four inches in length, from the posterior superior spinous 

Fig. 351. 




Line for— A. Gluteal artery. B. Sciatic and internal pudic artery. (Stimson.) 



process of the ilium to a point midway between the tuber 
ischii and the great trochanter (Fig. 351, A). After divi- 
sion of the skin and fascia, the fibres of the gluteus maxi- 
mus muscle are separated and held apart and the deep 
fascia is divided, and the artery should then be sought for 
above the pyriformis muscle at the upper border of the 
great sacro-sciatic notch. It is accompanied by large 



LIGATION OF THE FEMORAL ARTERY. 



441 



veins, injury to which should be avoided in exposing the 
artery and passing the needle. 

Ligation of the Sciatic and Internal Pudic Arteries. 
The incision is three or four inches in length, a little lower 
than that employed for exposure of the gluteal artery (Fig. 
351, B). Divide the skin, superficial fascia, and fibres of 
the gluteus maximus muscle and deep fascia, and search 
for the vessels as they leave the great sciatic notch at the 
lower edge of the pyriformis muscle. The internal pudic 
artery enters the pelvis through the lesser sciatic notch, 
lying on the inner side of the sciatic artery during its pas- 
sage over the spine of the ischium. The vessels are isolated 
and the needle is passed so as to avoid injury of the veins. 

Ligation of the Femoral Artery. The femoral artery 
may be ligated just below Poupart's ligament, at the apex 
of Scarpa's triangle, at the middle of the thigh, or in 
Hunter's canal. 

Fig. 352. 




Relations of the right femoral artery below Poupart's ligament. (Esmarch. 



Femoral Artery below Poupart's Ligament. The incision 
begins midway between the anterior superior spinous 
process of the ilium and the symphysis pubis, one-fourth 



442 OPERATIONS. 

of an inch above Poupart's ligament, and extends two 
inches downward. Divide the skin and superficial fascia 
and the deep fascia so as to expose the sheath of the 
vessels; open this one-half an inch below Poupart's liga- 
ment and isolate the femoral artery from the femoral vein 
which lies to the inner side; the anterior crural nerve lies 
to the outer side. Pass the needle from within outward 
(Fig. 352). 

Femoral Artery at the Apex of Scarpa's Triangle. The 
incision is three inches long, the centre of which should be 
a little above the point where the sartorius muscle crosses 

Fig. 353. 



\ 



Lines of incision for the femoral artery. (Stimson.) 



a line drawn from the middle of Poupart's ligament to 
the inner condyle of the femur (Fig. 353). Divide the 
skin, superficial and deep fascia, avoiding the internal 
saphenous vein, and expose the edge of the sartorius 
muscle, which may be recognized by the direction of its 
fibres. This muscle is drawn outward and the sheath of 
the vessels is exposed and opened; the vein lies on the 
inner side and somewhat behind the artery, and the long 
saphenous nerve is on the outer side (Fig. 354). Pass the 
needle from within outward. 

Femoral Artery in the Middle of the Thigh. The incisioii 
is in the line above mentioned, its centre being a little 
above the middle of the thigh. Divide the skin, super- 



LIGATION OF THE FEMORAL ARTERY. 



443 



ficial and deep fascia, and expose the sartorius muscle, 
which is drawn outward after the leg has been flexed ; the 
sheath of the vessels is exposed and opened ; the long 
saphenous nerve lies upon the artery and the femoral vein 



Fig. 354. 



Fro. 355. 





Relations of right femoral artery 
at the apex of Scarpa's triangle. 
(Esmarch.) 



Relations ot the right femoral ar- 
tery in the middle of the thigh. 
(Esmarch.) 



lies behind the artery; the saphenous vein lies more super- 
ficially and internal to the vessel. Pass the needle from 
within outward (Fig. 355). 

Femoral Artery in Hunter's Canal. The incision is three 
inches in length along the tendon of the adductor magnus, 
the centre of which is at the junction of the lower and 
middle thirds of the thigh (Fig. 353). Divide the 
skin, superficial and deep fascia, care being taken not to 
injure the internal saphenous vein, which should be dis- 
placed, and expose the sartorius muscle, which should be 
displaced downward, and expose the aponeurosis which 
forms the anterior wall of the vascular canal; this should 
be opened upon a director, and the artery is uncovered 
and should be separated from the vein which lies upon 
the outer side. The needle is passed from without inward. 



444 



OPERATIONS. 



Ligation of the Popliteal Artery. The incision is 
three or four inches in length, along the external border 
of the semi-membranosus muscle. Divide the skin and 
superficial fascia, taking care not to injure the sapheneous 
vein, and open the deep fascia. The edges of the wound 
being held apart the adipose tissue is broken up with a 
director, and the internal popliteal nerve will be first ex- 
posed, and next the vein — both external to the artery (Fig. 
356). The artery is isolated and the needle passed from 
without inward. 



Fig. 356. 




Relations of the right popliteal artery. (Esmabch. 



Ligation of the Anterior Tibial Artery. The anterior 
tibial artery may be tied in the upper, middle, and lower 
thirds of the leg; the general direction of the artery cor- 
responds with a line drawn from the middle of the space 



LIGATION OF THE ANTERIOR TIBIAL ARTERY. 445 

between the head of the fibula and the tubercle of the tibia 
to the middle of the anterior intermalleolar space. 

Anterior Tibial Artery in the Upper Third of the Leg. The 
incision is two and a half to three inches in length, one 
and one-fourth inches external to the spine of the tibia. 
Divide the skin and superficial fascia, and when the deep 
fascia is exposed open it on a line corresponding to the 
intermuscular space between the tibialis anticus and the 

Fig. 357. 




Ligation of the anterior tibial artery at its upper third. (Stimson.) 



extensor longus digitorum muscles. Separate the muscles 
and work down in this interspace until the artery is found 
with a vein on either side of it, and the anterior tibial 
nerve externally (Fig. 357). The needle should be 
passed from without inward after isolating the veins. 

Anterior Tibial Artery at its Middle Third. The incisiori 
is three inches in length in the same line as that for the 
upper portion of the vessel. After dividing the skin, 
superficial and deep fascia, the interspace between the 



446 



OPERATIONS. 



tibialis anticus and the extensor longus digitorum muscles 
is opened and a third muscle comes into view, the extensor 
proprius pollicis. The artery lies between the extensor 
proprius pollicis and the tibialis anticus muscles; and the 
anterior tibial nerve is to the outer side. The veins 
should be isolated and the needle should be passed from 
without inward. 

Anterior Tibial Artery in its Lower Third. The incision 
is two inches in length, beginning three inches above the 
ankle-joint on the line of the artery. Divide the skin, 
superficial and deep fascia, and seek for the tendon of 

Fig. 358. 



Extensor 

brevis digitorum 

muscle. 




Ligation of the dorsalis pedis artery. (Bryant.) 



the extensor proprius pollicis muscle, the second tendon 
from the tibia. The artery is found in the interspace 
between this tendon and the tendon of the extensor longus 
digitorum muscle, the nerve being to the outer side. The 
veins are isolated from the artery, and the needle is passed 
from without inward. 



LIGATION OF POSTERIOR TIBIAL ARTERY. ±£\ 

Ligation of the Dorsalis Pedis Artery. The incision 
is one inch in length on a line drawn from the middle of 
the anterior intermalleolar space to a point midway be- 
tween the extremities of the first two metatarsal bones or 
along the outer border of the tendon of the extensor pro- 
prius pollicis. Divide the skin, superficial and deep fascia, 
and the artery will be found lying next to the inner tendon 
of the short extensor muscle of the toes (Fig. 358). The 
nerve is to the outer side. After separating the veins the 
needle is passed from without inward. 

Ligation of the Posterior Tibial Artery. The course 
of the posterior tibial artery is indicated by a line drawn 

Fig. 359. 




Lines of incision for the posterior tibial artery. (Stimson.) 



from the middle of the popliteal space to a point midway 
between the tendo-Achillis and the internal malleolus of 
the tibia. 



448 



OPERATIONS. 



The posterior tibial artery may be ligated in its upper, 
middle, and lower thirds. 

Posterior Tibial Artery at its Upper Third. The incision 
is three inches and a half in length, one-half inch from 
the inner edge of the tibia, beginning two inches from the 
upper edge of the bone (Fig. 359). Divide the skin and 
superficial fascia, avoiding large superficial veins; next 
open the deep fascia and detach the origin of the soleus 
muscle from the tibia, and on raising it the under surface 



Fig. 360. 




Relations of the right posterior tibial artery in its upper third. (Esmarch.) 

will present a white, shining sheath of tendinous material, 
beneath which will be seen a layer of fascia covering the 
tibialis posticus muscle. If search is made toward the 
middle of the leg the artery will be found covered by the 
intermuscular fascia, the nerve being to the outer side. 
The needle is passed from without inward after the veins 
have been separated from the artery (Fig. 360). 

Posterior Tibial Artery at its Middle Third. The incision 
is two and a half inches in length, parallel with the inner 



LIGATION OF POSTERIOR TIBIAL ARTERY. 449 

edge of the tibia and half an inch from its border. Divide 
the skin, superficial and deep fascia, and the inner edge 
of the soleus will be exposed; press this outward and the 
artery with its veins will be exposed, also the posterior 
tibial nerve to the outer side. Pass the needle from with- 
out inward after separating the veins. 

Posterior Tibial Artery Behind the Inner Malleolus. The 
incision is a curved one two inches in length, midway be- 
tween the tendo-Achillis and the internal malleolus (Fig. 
359). Divide the skin and superficial fascia, then lift 

Fig. 361. 




Ligation of the posterior tibial artery behind the inner malleolus. (Bryant.) 

the deep fascia upon a director and open it freely, when 
the artery will be exposed, with the tendons of the tibialis 
posticus and flexor longus digitorum muscles on the inner 
side and the posterior tibial nerve and the tendon of the 
flexor longus pollicis muscle on the outer side (Fig. 361). 
After separating the veins from the artery the needle 
should be passed from without inward. 



29 



PART VI. 



AMPUTATIONS 



The term amputation is now generally applied to the 
removal of a limb, and this may be removed through the 
bones, when the operation is spoken of as an amputation 
in the continuity of the limb; or it may be removed through 
its joints, and it is then known as an amputation in the 
contiguity or a disarticulation. 



Methods of Amputating. 

Fig. 362. 




Amputation by circular method. (Druitt.) 

Amputations may be performed by the circular, flap, 
oval, and elliptical methods ; and the modified circular 



METHODS OF AMPUTATING. 451 

operation and Teale's method by rectangular flaps are 
also employed. 

Circular Method. In performing an amputation by this 
method the incision of the skin is made at a distance below 
the point where the bone is to be divided. An assistant 
grasps the limb and draws the skin eveuly and firmly 
toward the root of the part and the surgeon passes the heel 
of the knife well into the tissues and makes a circular sweep 
around the limb and completes the division of the skin and 
cellular tissue with one motion of the knife (Fig. 362). 

In some cases a cutaneous sleeve, consisting of the skin 
and cellular tissue, is dissected up and turned back, and 
sometimes it may be necessary to make a slit on one side 
of the flap, to allow it to be turned up. 

The second incision in an amputation by the circular 
method consists, after retraction of the skin, in making a 
circular cut through all of the tissues down to the bone 
(Fig. 363). 

Fig. 363. 




Division of muscles in circular amputation. (Smith.) 

The third step in an amputation by the circular method 
consists, after retracting the skin and muscles and holding 
them back by a retractor, in the division of the bone with 
a saw. 

Flap Method. This method of amputating is susceptible 
of many variations. There may be one or two flaps of 



452 



AMPUTATIONS. 



equal or unequal length ; the flaps may be cut antero- 
posteriorly, laterally, or obliquely (Fig. 364). They may 
be made by transfixing the limb and cutting outward, or 



Fig. 364. 




Double-flap amputation ; antero-posterior and lateral flaps. (Smith.) 

they may be cut from without inward; they may be made 
to include the whole thickness of the tissues down to the 
bone, or merely the skin and superficial fascia, the deeper 




Amputation by antero-posterior flaps. (Bryant.) 



structures being divided by a circular incision. The flaps 
may have a curved outline or may be rectangular in shape. 



METHODS OF AMPUTATING. 453 

In amputating by the antero-posterior flap operation the 
surgeon grasps the limb and enters the point of a long 
knife into the tissues at the side nearest himself, and push- 
ing it across and round the bone or bones brings its point 
out through the skin at a point diametrically opposite its 
point of entrance. He then shapes the flap by cutting 
downward with a rapid sawing motion and then cuts 
obliquely forward until all the tissues are divided. The 
flap being turned up, he re-enters his knife at the same 
point and passes it on the other side of the bone or bones 
and cuts the second flap in the same manner (Fig. 365). A 
retractor is next applied and the bone is divided with a saw. 
The Oval Method. The oval amputation is really a cir- 
cular one, in which the cuff of skin has been slit at one 

Fig. 366. 



Modified circular amputation. (Skey.) 

side and the angles rounded off. This is the form of am- 
putation frequently performed at the metacarpo-phalangeal 
and metatarso- phalangeal joints, and is one of the methods 
of amputation at the shoulder-joint. 

Elliptical Method. This is a form of the oval method 
of amputation which is employed in amputations at the 



454 AMPUTATIONS. 

knee-joint and elbow-joint, the incision forming an ellipse, 
coining below the joint on the front or outside of the limb, 
the resulting nap being folded upon itself. 

Modified Circular Method. In this method of ampu- 
tation two oval skin flaps, antero-posterior or lateral, are 
turned up, and the muscles are next divided by a circular 
sweep of* the knife down to the bone (Fig. 366). 

Teale's Method by Rectangular Flaps. In this method of 
amputation two flaps are made of unequal length ; the 
incisions are so planned that the shorter flap contains the 
main vessel or vessels. The flaps are cut of equal width 
and the leugth of the long flap should be one-half of the 

Fig. 367. 




V 

Teale's method of ainputatiou. (Bryant.) 

circumference of the limb at the point where the bone is 
to be divided; the length of the short flap should be one- 
eighth of the circumference of the limb. The flaps are 
cut from without inward, and embrace all of the tissues 
of the limb down to the bone. After the flaps have been 
dissected up the bone is divided with a saw, and the long 
flap is folded over and sutured to the short flap (Fig. 367). 
The disadvantage of this method of amputation is that 
in muscular limbs it requires the bone to be divided at a 
higher point than would otherwise be necessary. 



INSTRUMENTS REQUIRED FOR AMPUTATIONS. 455 

Periosteal Flaps. In any of the methods of amputation 
previously described the periosteum may be dissected up 
in two flaps attached to the muscles, or pushed up as a 
sleeve by means of a director or periosteotome before the 
bone is sawed. This procedure is most easily accomplished 
in young subjects. When these flaps are made and are 
brought together, the periosteum covers the cut surface 
of the bone, to which it soon forms adhesions. 

Instruments Required for Amputations. The instru- 
ments required for amputations are knives of various shapes 
and sizes, saws, dissecting forceps, bone forceps, artery for- 
ceps, tenacula, haemostatic forceps, scissors, periosteotomes, 
tourniquets, Esmarch ? s bandage and strap, retractors, liga- 
tures, sutures, and needles. 

Amputating Knives. The knives required for amputa- 
tions vary according to the method of amputation and the 
part to be amputated. In certain amputations a scalpel 



Fig. 368. 



Scalpel. 



*i&e&&®&@M&^ /u ~ 



(Fig. 368) or straight bistoury (Fig. 869) may be used, 
while in other cases the employment of amputating kuives 
of various sizes will be found more satisfactory. For 
amputations of the thigh a knife with a blade of eight or 



Fig. 369. 



Straight bistoury. 



nine inches is generally employed, and for smaller limbs 
a knife with a blade of six or seven inches in length; 
double-edged catlins are employed in amputations of the 
leg and forearm, to divide the interosseous tissues before 
applying the saw. The amputating knives now employed 
are constructed with solid metal handles, so that they can 



456 



AMPUTATIONS. 



be rendered thoroughly aseptic by immersion in boiling 
water before being used (Fig. 370). 

Amputating Saws. Several kinds of amputating saws 
are in general use; one with a blade ten inches long by 
two and a half inches wide, with a heavy back to give it 



Fig. 370. 



Amputating knife and catlin. 



additional firmness, is a very good variety of saw (Fig. 
371). For amputations about the foot or hand a narrow 



Fig. 371. 




Amputating saw. 



saw with a movable back will be found very convenient 
(Fig. 372). A bow saw with a metallic handle and a 



Fig. 372. 



"^-V-V-V^ 



Small amputating saw. 







reversible blade is a very useful variety of saw, as it can 
be used either in amputations or in excisions, and, being 
constructed entirely of metal, it can be easily rendered 
aseptic (Fig. 373). 



INSTRUMENTS REQUIRED FOR AMPUTATIONS. 457 

Fig. 373. 




Vyi* ) F> r lV*^v^ 



Amputating saw with reversible blade. 



Bone-forceps, or Cutting Pliers. These instruments are 
used iu smoothing off any rough edges of bone left after 
the use of the saw, or for the division of the small bones 



Fig. 374. 




Bone-forceps, or cutting pliers. 

in amputations of the fingers and toes. The forceps 
should be from ten to twelve inches in length, with blades 
from one to one and a half inches in length (Fig. 374). 

Periosteotome. The periosteotome, or raspatory, is em- 
ployed for dissecting up a flap of periosteum, which, after 

Fig. 375. 




Periosteotome. 

sawing the bone, is drawn down over the sawed end of the 
bone (Fig. 375). 

Artery Forceps and Tenacula. These instruments are 
used for taking up the vessels, and one of the best forms 
of artery forceps is that known as the double-spring artery 
forceps (Fig. 226). Tenacula are also employed for the 



458 



AMPUTATIONS. 



same purpose (Fig. 227). Haemostatic forceps will also be 
found most useful in cases of amputation, for the rapid 
control of hemorrhage from small vessels after the tour- 
niquet has been removed, the vessels being secured by 
torsion or by ligatures before the haemostatic forceps are 
removed. 

Retractors. These consist of pieces of muslin six or 
eight inches in width, one end of which is split into two 
or three tails; the former variety of retractor is employed 
where one bone is divided, as in amputations of the arm 
and thigh, and the latter in cases where two bones are 
divided, as in amputations of the forearm and leg (Fig. 
376). 

Fig. 376. 




Retractor applied. (Esmarch.) 



Ligatures. The best material to employ for the ligature 
of vessels is plain or chromicized catgut or sterilized 
silk, the preparation of which has been described (p. 134). 

Sutures. The materials employed for sutures in cases of 
amputation may be silkworm-gut, catgut, silk, or silver 
wire; deep or buried sutures of catgut, in bringing together 



DETAILS OF AN AMPUTATION. 



459 



the edges of the periosteal flaps, muscles, and fascia, are 
often employed with advantage in amputations (Fig. 377), 
the skin flaps being brought together with interrupted or 
continuous sutures of silk, catgut, silkworm-gut, or silver 
wire (Fig. 378). 



Fig. 377. 



Fig. 37* 




Deep or buried sutures of muscles. 
(Esmarch.) 



Sutures of the skin. 
(Esmarch.) 



Tourniquets. For the control of hemorrhage during the 
amputation the Esmarch apparatus (Fig. 225) or Petit 7 s 
tourniquet (Fig. 219) is employed; or the employment of 
both at the same time will often be found most satisfac- 
tory. The Esmarch bandage and tube being applied, after 
removal of the bandage, the tourniquet of Petit is loosely 
applied at a higher point, and after the main vessels have 
been secured the elastic strap is removed, and the tour- 
niquet is screwed down and controls the bleeding until the 
smaller vessels have been secured by ligatures. Wyeth's 
pins may be used in conjunction with the elastic strap in 
amputations at the hip-joint and shoulder- joint. 

Details of an Amputation. The following are the 
steps of an amputation of the lower part of the thigh : 

The skin is first thoroughly cleansed by rubbing it with 
turpentine, soap and water, and alcohol. It is then washed 
with a solution of bichloride of mercury, 1 : 2000. Pro- 
vision is next made to prevent the loss of blood during the 
operation by the application of Esmarch' s bandage and 



460 



AMPUTATIONS. 



tube; the bandage being removed a tourniquet is placed 
over the femoral artery in Scarpa's triangle and loosely 
secured. The limb is again washed with bichloride solu- 
tion. The instruments having been previously thoroughly 
sterilized, a rubber cloth covered with towels wrung out 
in a bichloride solution is placed under the limb. The 
variety of amputation having been decided upon, the flaps 
are cut and the muscles are divided down to the bone; 
the periosteum being dissected up, a two-tailed retractor is 
applied, and the tissues are held back by an assistant while 
the surgeon divides the bone with the saw. When the 
bone has been divided the retractor is removed, and the 

Fig. 379. 




Stump showing application of sutures and drainage-tubes. (Smith.) 

surface of the wound is irrigated with a 1 : 2000 bichloride 
solution. The femoral artery and vein are next found 
and secured with ligatures, and any branches which can be 
found are also secured. The elastic strap is removed after 
screwing down the tourniquet, aud by gradually letting up 
the pressure on the smaller vessels which bleed, are picked 
up with artery forceps or hemostatic forceps and secured. 
After all bleeding has been controlled the tourniquet is 
removed, and the wound is again thoroughly irrigated 



RE-DRESSING OF AMPUTATIONS. 461 

with a 1 : 2000 bichloride solution. If there is much 
oozing from the smaller vessels, this solution should be as 
hot as the hands of the operator can comfortably stand, 
which will act promptly in controlling this variety of 
bleeding. The periosteal flaps, if they have been made, 
are brought together by two or three catgut sutures, and a 
drainage-tube is next introduced, or two short tubes are 
introduced at either extremity of the wound and secured 
by sutures or safety-pins; the muscles should next be 
brought together by a few deep or buried sutures of catgut, 
and the skin flaps should then be brought into apposition 
by a number of interrupted sutures (Fig. 879). The 
inner surface of the stump is next irrigated by a stream of 
bichloride solution introduced through the drainage-tube, 
and the surface of the stump is washed with the same 
solution; a piece of protective or silver foil is next placed 
over the line of the wound, and over this is placed a moist 
bichloride gauze dressing, and over this a number of layers 
of dry gauze; this is next covered by rubber-tissue and 
a number of layers of bichloride cotton, or, if the dry 
method of dressing is preferred, the rubber-tissue is 
omitted and a number of layers of bichloride cotton are 
laid over the gauze dressing, and the whole dressing is 
held in place by a recurrent bandage of the stump. 

If the aseptic method is employed, no antiseptic solu- 
tions are brought in contact with the wound, sterilized 
water only being used if it is necessary to flush the wound, 
and after bringing the flaps together a sterilized gauze 
dressing is applied. 

Re-dressing of Amputations. The first dressing of 
an amputation, if strict antiseptic precautions have been 
observed at the time of operation, need not, as a rule, be 
made for a week or ten days, except in cases where the 
oozing is so profuse as to soak the dressings, or where 
consecutive hemorrhage has occurred, or the patient's 
condition shows that the wound is not running an aseptic 
course. The re-dressing of a stump can be accomplished 
without pain to the patient if the surgeon and his assist- 
ants are careful in their manipulations. 



462 AMPUTATIONS. 

The dressings to be applied, the solutions for irrigation, 
and the instruments required should be prepared and at 
hand before the stump is exposed. The surgeon and his 
assistants should wash their hands carefully, and then 
soak them in a 1 : 2000 bichloride solution. The bandage 
retaining the dressings to the stump should be divided 
with bandage scissors without lifting the stump from the 
pillow upon which it rests. After the bandage has been 
divided and turned aside, the gauze dressing is next 
unfolded and turned down; an assistant now slips his 
hands under the stump and gently raises it from the 
dressings, and at the same time a rubber cloth covered 
with towels which have been wrung out in a 1 : 2000 
bichloride solution is slipped under the stump and the 
soiled dressings are removed. The protective covering 
the incision is next removed and the surface of the stump 
is irrigated with a 1 : 2000 bichloride solution ; the drain- 
age-tubes are next examined and the cavity of the stump 
irrigated with the bichloride solution through the tubes 
by means of a syringe or an irrigating apparatus, or the 
irrigation may be omitted. 

If the wound is aseptic and there seems to be no further 
indication for the use of the drainage-tubes, they may be 
removed. The sutures are next examined, and if the 
wound is firmly healed alternate sutures maybe removed; 
if catgut or silkworm-gut sutures have been used, they 
need not be disturbed at this dressing, and their removal 
may be postponed until a subsequent dressing. 

The wound should next be covered with a gauze dress- 
ing consisting of a number of layers, and over this several 
layers of bichloride cotton, and the dressings should be 
held in place by a recurrent bandage of the stump. In 
holding the stump the assistant should hold it firmly to 
prevent muscular spasm, and after the dressings have 
been secured it should be placed upon a clean pillow pre- 
pared for its reception. The same procedures are adopted 
at subsequent dressings, and if the wound has run an 
aseptic course, two or three dressings, at most, will be 
required. 



AMPUTATIONS OF THE FINGERS. 



463 



Amputations of the Hand. 

Amputations of the Fingers. The fingers may be 
amputated in the continuity of the phalanges or in their 
contiguity, and, as a rule, as it is important to save as 
much as possible of the finger, the former method is 
generally to be employed instead of disarticulation at a 
higher point. The incision should be so planned that 
the cicatrix does not occupy the palmar surface; the 
larger flap should, therefore, be taken from the palmar 
aspect of the finger. In amputating the phalanges of the 
fingers in their continuity, the circular method (Fig. 384, 
B) or a short dorsal flap and a long palmar flap may be 
employed. In disarticulating a phalanx it is best to enter 
the joint with a narrow knife from the dorsal side, and 
after having carried it through the joint, to cut a long 
palmar flap, keeping close to the bone (Fig. 380). In 

Fig. 380. 





Amputation of a finger by the luug palmar flap. (After Esmarch.) 



locating the position of the phalangeal joints, it is well to 
remember that the prominence of the knuckle when the 
finger is flexed is formed entirely of the head of the prox- 



464 



AMPUTATIONS. 



imal and not of the base of the distal phalanx (Fig. 381), 
and also that the folds on the palmar surface of the finger 
do not correspond exactly to the joints (Fig. 382). 



Fig. 381. 




Fig. 382. 




Phalanges flexed. Guides to articulations of the fingers. (Smith.) 



Amputation of the Finger through the Metacarpo- 
phalangeal Articulation. In this variety of amputation 
an incision is made from a point on the dorsal surface of 
the metacarpal bone a quarter of an inch above the articu- 
lation, which is carried through the interdigital web and 
back upon the palmar surface to a point a quarter of an inch 
above the flexor fold (Fig. 384, C). A similar incision 
begiuning and ending at the same points is made upon the 
opposite side of the finger. The flaps are dissected back, and 
the lateral ligaments, tendons, and remainder of the capsule 
are divided (Fig. 383). The finger may also be amputated 
at the metacarpophalangeal joint by making an incision on 
one side and dissecting the flap back to the joint, then divid- 
ing the lateral ligament, opening the joint and carrying the 
knife across this, dividing the tendons and lateral liga- 
ment on the other side and cutting a flap from within 
outward. 



AMPUTATIONS OF THE METACARPAL BONES. 465 

Removal of the head of the metacarpal bone if desired 
may be accomplished by the use of catting pliers (Fig. 
385); but, as a rule, this procedure is not to be recom- 
mended, for, although the deformity is lessened, the 
strength of the hand is diminished. 



Fig. 




Racket-shaped incision for amputation of the finger at metacarpo-phalangeal 
joint. (After Rotter.) 



In amputating the little and index fingers a full lateral 
flap may be cut on the free side and an incision is next 
carried across the palmar surface to the angle of the web 
and thence back to the joint, which is opened and the dis- 
articulation effected (Fig. 384, E). 

Amputations of the Metacarpal Bones. In ampu- 
tating the metacarpal bones it is advisable to leave the 
carpal ends of the bones to avoid opening the wrist- joint, 
except in the case of the first and fifth metacarpal bones, 

30 



466 AMPUTATIONS. 

which do not communicate with the others and with the 
synovial sacs. 

Fjg. 384. 



A. Disarticulation of phalanx; palmar flap. B. Amputation in continuity 
by a circular Hap. C. Metacarpophalangeal disarticulation. D. Amputation 
of metacarpal bone in continuity. E. Disarticulation of little finger. F. Dis- 
articulation of fifth metacarpal bone. O. Amputation at the wrist, circular. 
H. Amputation at the wrist, lateral. (Stimson.) 

The incisions for the removal of the metacarpal bones 
are the same as for the removal of a finger at the meta- 
carpophalangeal joint, the incision being prolonged back- 
ward as far as necessary over the dorsal surface of the 
bone (Fig, 384, D). After the metacarpal bone has been 
bared for a sufficient distance, it is cut through with bone- 
pliers or disarticulated, and the distal end is raised from 
its bed and carefully separated from the soft parts, care 
being taken to avoid injury of the structures of the palm 
of the hand. 



AMPUTATIONS OF THE METACARPAL BONES. 467 

In amputating the fifth metacarpal bone the incision 
should be made along the inner border of the hand and 
carried down to the bone between the skin and the ab- 

Fig. 385. 




Removal of the head of a metacarpal hone. (Skey. 



ductor minimi digiti muscle (Fig. 386). The lower end 
of the incision passes over the knuckle to the web of the 
finger, and backward under the palmar surface to join the 
first incision. 

Amputation of the entire thumb with its metacarpal 
bone is effected by making an oval flap from the palmar 
surface; in the case of the left thumb the joint may be 
opened by an oblique incision on the dorsal surface of the 
hand, beginning a little in front of the joint and being 
carried down to the web between the thumb and forefin- 
ger; the palmar flap is then made by thrusting the knife 
upward to its point of entrance and cutting downward 
and outward. In amputating the right thumb with its 



468 



AMPUTATIONS. 



metacarpal bone it is better to make the palmar flap first 
by transfixion, the dorsal flap being made subsequently. 




Incision for removal of the fifth metacarpal bone. (Smith.) 

Amputation of the hand at the ear po-metacarpal joint is 
occasionally performed, or between the rows of carpal 
bones; but is not, as a rule, to be recommended, as the 
carpal bones are apt subsequently to become diseased and 
require removal; it is, therefore, better to amputate at the 
radio-carpal joint. 



Amputations at the Wrist. 



Circular Method. 

wrist being retracted 



The skin of the forearm near the 
by an assistant, a circular incision 
of the skin and cellular tissue is made half an inch below 
the point of the styloid process of the radius (Fig. 384, G). 
The skin and cellular tissue are next dissected back as far 
as the joint, which is opened and the disarticulation is com- 
pleted. 

Antero-posterior Flap Method. This method is also 
employed in amputations at the wrist-joint; an incision 
curved downward is made on the back of the hand from 



AMPUTATIONS OF THE FOREARM. 469 

one styloid process to the other; the hand being flexed the 
tendons are divided and the joint opened, and the palmar 
flap, which should extend as far as the base of the meta- 
carpal bones, is cut from within outward (Fig. 387). 

Fig. 3S7. 



Amputation at the wrist. (Erichsen.) 

Amputation at the wrist is sometimes performed by cut- 
ting a single flap from the palm, the joint being opened 
by a transverse incision on the back of the hand from one 
styloid process to the other. 

Lateral Flap Method. This method (Fig. 384, H) is 
also sometimes employed in amputation at the wrist, and 
may be employed with advantage in cases of laceration of 
the hand, in which the injury to the tissues prevents the 
formation of the flaps used in the other methods of ampu- 
tation. 

Amputations of the Forearm. 

The forearm may be amputated by the circular or flap 
methods, or by making rectangular flaps (Teale's method). 

Circular Method. At the lower portion of the forearm 
the circular method of amputation is to be preferred. A 
circular incision of the skin and cellular tissue is made and 



470 AMPUTATIONS. 

a cuff is dissected up, the muscles and interosseous mem- 
brane being cut through; a three-tailed retractor is next 
applied and the bones are divided with a saw. 

Oval Method. Amputation of the forearm by the oval 
or mixed method, which consists in first dissecting up two 
antero-posterior oval flaps of skin and cellular tissue and 
then dividing the muscles by a circular iucision, is also a 
satisfactory operation (Fig. 388). 

Fig. 388. 




Amputation of the forearm by the modified circular method. (Bryant.) 

In amputation at the upper portion of the forearm, 
antero-posterior or lateral flaps, cut from without inward 
or by transfixion, or rectangular flaps may be made with 
advantage. 

Amputations at the Elbow. 

The methods of amputation employed at the elbow are 
the anterior flap, lateral flap, circular, and elliptical. 

Anterior Flap Method. A flap of three inches in 
leugth, with its base parallel to and half an inch below 
the condyles of the humerus, is cut either by transfixion 
or from without inward. The joint is next opened and 
the lateral ligaments divided. The olecranon is then ex- 
posed and the attachment of the triceps muscle separated 
and a posterior flap is cut from without inward, or from 
within outward, a little below the line of the condyles 
(Fig 389, A). 

Lateral Flap Method. In amputation at the elbow- 
joint lateral flaps may be employed, cut either from with- 
out inward or by transfixion (Fig. 389, B). An external 
flap three inches in length is made on the outer side of the 
forearm, starting from a point a finger's breadth below the 



AMPUTATIONS AT THE ELBOW. 



471 



bend of the elbow, by transfixion or by cutting from with- 
out inward; a shorter internal flap is next cut in the same 
manner, and the joint is opened and the disarticulation is 
effected. 



Fig. 390. 




Circular amputation at the elbow. (Smith. ) 




Amputation at the elbow-joint. A. An- 
terior flap method. B. External flap ire- 
thod. C. Circular method. (Stimson.) 



Incision for elliptical amputation 
at the elbow. (After Treves.) 



Circular Method. An incision dividing the skin and 
cellular tissue is made around the limb three inches below 
the line of the condyles of the humerus (Fig. 389, C), 
the skin is dissected up and a circular incision made 



472 AMPUTATIONS. 

through the muscles, the joint is opened and the disar- 
ticulation is effected (Fig. 390). 

Elliptical Method. In this method of amputating at 
the elbow an incision is carried from the olecranon process 
downward and forward to a point a little above the middle 
of the forearm. The incision is then continued across the 
anterior aspect of the limb, and is carried back to the 
olecranon process (Fig. 391). The incision involves only 
the skin and the cellular tissue. The flap having been 
dissected up for a short distance, the soft parts close to the 
joint are transfixed; the muscles are cut obliquely, so that 
an anterior flap is formed. This flap is held up, the bones 
are disarticulated, the attachment of the triceps tendon to 
the olecranon is divided, and any tissues which have 
escaped division along the posterior aspect of the limb 
are severed. After the vessels have been secured the 
flap is turned over and sutured, and a curved cicatrix on 
the posterior aspect of the limb results. 

Amputations of the Arm. 

The arm may be removed at any point below the attach- 
ment of the muscles at the axilla, by either the circular, 
flap, oval, or modified circular methods. 

Circular Method. This operation is usually employed 
in removing the arm in its lower third: a circular in- 
cision of the skin and subcutaneous tissue is first made, 
and when the cuff has been dissected up a circular division 
of the muscles is made, and after applying the retractor the 
bone is sawed through (Fig. 392). 

Flap Method. From the central position of the bone 
in the arm the flap method in amputating the arm is pre- 
ferred by many operators. The arm being grasped by the 
hand the point of a medium-sized amputating knife is 
thrust through the arm so as to pass over the humerus 
and make its exit at a corresponding point in the skin on 
the opposite side; a flap of sufficient length is cut from 
within outward. The knife is next passed behind the 
bone and a posterior flap is cut in the same manner (Fig. 



AMPUTATIONS OF THE ARM. 



473 



393); the bone is next cleared of muscular tissue, the flaps 
are retracted, and it is divided with a saw. 



Fig. 392. 




Circular amputation of the arm. (Smith.) 

Lateral flaps may be made in this amputation in the 
place of the antero-posterior flaps, and they may be cut 
from within outward in the same manner. 



Fig. 393. 




Amputation of the arm by flap operation. (Bryant.) 

Modified Oval Method. This method of amputating 
the arm is also employed with advantage. Two oval flaps 
of skin and cellular tissue are cut and dissected up, and 



474 AMPUTATIONS.. 

the muscles are next divided by a circular sweep of the 
knife. 

In high amputations of the arm there is sometimes not 
room enough to apply Esinarclr's strap or a tourniquet to 
the arm itself to control the hemorrhage during the opera- 

FlG. 394. 




Esmarch's strap applied in high amputation of the arm. (Smith.) 

tion, and in such cases the strap may be passed from the 
axilla around the outer end of the clavicle, as is done to 
control the bleediug during amputation at the shoulder- 
joiut (Fig. 394), or Wyetlr's pins may be employed. 

Amputations at the Shoulder-joint. 

Several methods of operation are employed in ampu- 
tating at the shoulder-joint, such as the oval or Larrey's 
method, flap method, as Lisfranc's and Dupuy trends 
methods, and Spence's method (Fig. 395). The control of 
the bleeding from the axillary artery during the operation 
is a matter of the first importance, and it may be arrested 
by pressure made upon the subclavian artery, as it crosses 
the first rib, with the thumb, or the padded handle of a 
large key, or by the fingers of an assistant grasping the 
axillary flap and compressing the vessel after the head of 
the bone has been disarticulated, or by the use of an 



AMPUTATIONS AT THE SHOULDER- JOINT. 475 

elastic strap applied around the axilla and shoulder (Fig. 
394). 

Fro. 395. 




Amputation at the shoulder-joint. A. Oval, or Larrey's method. 
B. Double-flap, or Dupuytren's method. (Stimson.) 

Wyeth's pins may also be employed with an elastic tube 
or strap to control bleeding during amputation at the 

Fig. 396. 




Method of applying Wyeth's pins. 



shoulder-joint. The anterior pin is passed through the 
anterior fold of the axilla, and is brought out in front of 



476 



AMPUTATIONS. 



the acromion, the posterior pin is passed through the pos- 
terior fold of the axilla and is brought out behind the acro- 
mion, the rubber strap or tube is then wrapped around 
the shoulder behind the pins and controls the hemorrhage 
during the operation (Fig. 396). 

Oval, or Larrey's Method. In this method of ampu- 
tation the point of the knife is entered just below the acro- 
mion process and a deep incision three inches in length is 

Fig. 397. 




Amputation at the shoulder-joint by Larrey's method. 



made down to the head of the bone along the axis of the 
arm; from the middle of this incision two others are made 
obliquely downward to the points where the anterior and 
posterior folds of the axilla end in the tissues of the arm; 
the latter incisions should be only deep enough to divide 
the skin and superficial fascia (Fig 395, A). The flaps 
are then dissected up until the head of the bone is well 



A MP VTA TIONS A T THE SHO VLDER-JOINT. 477 

exposed, and, after opening the capsule and dividing the 
muscles inserted into the neck and tuberosities of the 
humerus, which division may be facilitated by rotating 
the head of the bone outward and inward, the disarticu- 
lation is effected by adducting the elbow; the knife is 
next passed downward behind the bone and made to cut 
outward in the line of the cutaneous incisions — an assistant 
controlling the artery before it is divided by grasping the 
axillary tissues behind the knife with his fingers. 

Flap, or Dupuytren's Method. In this method of 
amputation at the shoulder- joint the flaps may be cut 
either by transfixion or from without inward; the large 
flap embraces the greater part of the deltoid muscle (Fig. 
395, B), and the smaller or short flap is cut from the inside 




Amputation at the shoulder-joint. Dupuytren's method. (Bryant. 



of the arm after the head of the bone has been disarticu- 
lated. When cut by transfixion, the point of the knife 
should be entered an inch in front of the acromion process 
and pushed across the outer aspect of the head of the 
humerus, and should be brought out at the posterior fold 
of the axilla; the knife is made to cut downward until a 
large deltoid flap is formed. This flap is turned up, and 
the head of the bone is disarticulated; the knife being 



478 



AMPUTATIONS. 



placed behind it, a short flap is formed, keeping close to 
the bone, so that the vessels are divided with the last cut 
of the knife (Fig. 398). An assistant should control the 
vessel by grasping the axillary tissues with his fingers 
behind the knife. 

Double Flap, or Lisfranc's Method. In this method 
of amputation at the shoulder-joint the point of the knife 
is entered at the outer side of the coracoid process, and is 
carried across the outer aspect of the head of the humerus 
and brought out a little below the posterior border of the 
acromion process, and a long flap is cut downward. This 
flap is turned up and the attachments of the head of the 
bone are divided and it is disarticulated. The knife is 
again entered behind the bone, and a long posterior flap 
is cut from within outward. 



Fig. 399. 




Amputation at the shoulder-joint. Spence's method. (Stimson.) 

Spence's Method. In this method of amputation at 
the shoulder-joint an incision is made down to the head of 
the humerus immediately in front of the coracoid process, 
and is continued downward through the clavicular fibres 
of the deltoid and the pectoralis major muscles until the 
attachment of the latter to the humerus is reached (Fig. 



AMPUTATION ABOVE THE SHOULDER-JOINT. 479 

399). The incision is now carried backward to the pos- 
terior fold of the axilla. A second incision, including 
only the skin and cellular tissue, is next made from the 
anterior portion of the first incision across the inside of 
the arm to meet the incision on the outer part. The outer 
flap thus formed is turned up and the head of the bone is 
disarticulated. The operation is completed by dividing 
the remaining tissues on the axillary aspect. 

Many other methods of removing the arm at the shoul- 
der-joint have been devised and employed, including the 
circular method. 

Amputations Above the Shoulder-joint. This form 
of amputation consists in the removal of the arm with a 
part or the whole of the scapula and sometimes a portion 
of the clavicle. 

As this form of amputation is required in cases in which 
the laceration of the parts has passed beyond the shoulder- 
joint, or in cases of growths involving the tissues beyond 
the joint, no definite rule can be laid down for the 
incisions; the only rule being as far as possible to make 
them in such a manner that the least possible amount 
of skin is sacrificed, so that a sufficient covering for the 
wound can be obtained. Treves recommends the follow- 
ing method : The patient should be placed on his back 
close to the edge of the operating-table. An incision 
should be made over the clavicle, extending from the 
inner extremity outward to a point a littJe beyond the 
acromio-clavicular articulation, which should be carried 
down to the bone; the clavicle being exposed, it should 
be divided in its middle third or disarticulated from the 
sternum, and, its outer portion being lifted up, it is dis- 
articulated at its acromial extremity. The subclavian 
vessels are thus exposed, and should be tied by two liga- 
tures, about an inch apart, and the vessels should finally 
be divided beween the ligatures. The axillary plexus of 
nerves should next be divided. The second incision is 
made at the centre of the first incision, and the knife is 
carried directly across the anterior part of the axilla and 
inner border of the arm to the inferior angle of the 



480 



AMPUTATIONS. 



scapula; from the outer extremity of the first incision 
over the clavicle a third incision should be made poste- 
riorly, across the dorsum of the scapula to its inferior 
angle, joining the termination of the second incision (Fig. 
400). Upon turning back the posterior flap thus formed 



Fig. 400. 




Amputation of arm, scapula, and clavicle, the dotted line representing posterior 
incision. (Treves.) 

and severing the connections of the scapula with the trunk 
and the muscular attachments which remain anteriorly, 
the upper extremity will be entirely freed from the trunk. 
The wound, when closed, forms an oblique line running 
from above downward, outward, and backward. 



Amputations of the Foot. 

Amputations of the Toes. The phalanges of the toes 
may be removed in the same manner as those of the fin- 
gers. It is better to amputate at the metatarso-phalangeal 
articulations than to attempt to remove them at the joints 
in front of this articulation, except in the case of the great 
toe, as the preservation of a portion of a toe is rather a 
discomfort than an advantage, except in the instance men- 



AMPUTATIONS OF THE TOES. 



481 



tioned. All incisions should be made so that the result- 
ing cicatrix does not occupy the plantar surface, and it is 
well to remember that the web of the toes is considerably 
below the position of the inetatarso-phalangeal joint. 



Fig. 401. 



Fig. 402. 




Amputation ot the toes by the 
racket-shaped incision and flap 
method. (After Rotter.) 




Incisions for amputation of toes and 
metatarsal bones. (Stimson.) 



The toes are 
dorsal surface a 
down the bone 
the web, and is 
other side to the 

Amputation of 
should be made 



usually removed by an incision on the 

little above the joint, which is carried 

for about an inch and then diverges into 

carried under the toe and back on the 

point of divergence (Figs. 401, 402). 

Two Adjoining Toes. The dorsal incision 

in the inter-metatarsal space just above 

31 



482 



AMPUTATIONS. 



the level of the joint (Fig. 402, B) and carried down to 
the beginning of the web; then over the toes to the begin- 
ning of the adjoining web, then under the plantar surface 
of both toes in the line of the digito-plantar fold, through 
the web and back to the point of divergence. 

Amputation of the Great Toe. This may be accomplished 
by means of the racket-shaped incision employed in am- 
putation of the other toes (Fig. 401) or by means of a 
lateral flap. In the latter case the knife is made to enter 
the joint by cutting through the commissure, and the 
operation is completed by carrying the knife through the 
joint and along the outer side of the bone, forming a flap 
of the required size. 

In this amputation a short dorsal flap and long plantar 
flap may be employed, or a large internal flap may be used. 

Amputation of the Great Toe with its Metatarsal Bone. 
The incision begins upon the dorsal surface of the meta- 



Fig. 403. 




Amputation of the great toe and first metatarsal bone. (Smith.) 



tarsal bone, a little below the point at which the bone is 
to be divided, and is carried down below the metatarso- 
phalangeal joint, then diverges and passes under the toe 
and comes back again to the point of divergence (Fig. 
402, 0). The bone is exposed and cut through with cut- 



AMPUTATION OF THE METATARSAL BONES. 483 

ting forceps, and is then lifted up and dissected loose from 
the tissues (Fig. 403). 

Amputation of All the Toes. To amputate all the toes, 
make a dorsal incision from the head of the fifth to the 
head of the first metatarsal bone; the incision should be 
a curved one passing just in front of the joints (Fig. 404). 
Dissect up the flap and open the joints, dividing the lateral 

Fig. 404 




Incision for amputation of all the toes. (Smith.) 

ligaments, and pass the knife behind the phalanges and 
cut a flap from the plantar surface. 

Amputations of the Metatarsal Bones. It is better 
in these amputations to leave the tarsal head of the meta- 
tarsal bone in place and divide the bone, or, in other 
words, to do an amputation in continuity to prevent 
opening up the tarsal articulations. 

Amputation of the Little Toe and the Fifth Metatarsal Bone. 
The incision for the removal of the little toe and the fifth 
metatarsal bone is made over the bone a little below the 
metatarso-tarsal articulation, and is carried down and 
curved around the toe (Fig. 402, D), and after the bone 
is exposed by dissecting back the flaps, it is divided, or 
the joint is opened and it is dissected out. 

Amputation Through all the Metatarsal Bones. In per- 
forming this amputation an incision is made across the 
dorsum of the foot, and a short dorsal flap is dissected 
up; the metatarsal bones are next divided with a saw and 



484 



AMPUTATIONS. 



a long plantar flap is cut from within outward by entering 
the knife behind the ends of the bones. 

Tarso-metatarsal Amputations. In all amputations 
of the foot involving the tarsus the surgeon should be 
thoroughly familiar with the anatomy of the foot and the 
surgical landmarks of the different articulations. I shall 
refer to those laid down by Mr. Bryant, which are as 
follows: 



Fig. 405. 



Fig. 406. 





Surgical guides to the foot as expressed 
by anatomy. (Bryant.) 



Incision for— A. Lisfranc's am- 
putation. B. Chopart's amputa- 
tion. (Stimson.) 



" On the inner side of the foot, not far from the inner 
malleolus, the tubercle of the scaphoid (Fig. 405, J.), is to 
be felt as a marked prominence; about one-half an inch 
in front of this will be found the articulation with the 



TARSO-METATARSAL AMPUTATION. 485 

cuneiform bone (B), and one inch in front of this the 
joint which the surgeon will have to open in Lisfranc's 
or Hey's operation ((?); just above the tubercle of the 
scaphoid will be found the articulation with the astragalus, 
the line of Chopart's amputation (Z)). On the outer side 
of the foot, one inch below the external malleolus, a 
sharply denned projection will always be felt, which is 
the peroneal tubercle (E); one-half an inch in front of 
this will be found the joint which separates the os calcis 
from the cuboid (F), this joint forming the outer circle to 
Chopart's amputation. Half an inch in front again, or 
one inch from the tubercle, the prominence of the fifth 
metatarsal bone is always to be felt (H), the line above 
this prominence indicating the articulation with the cuboid 
bone, which forms the outer boundary of the incision for 
Hey's or Lisfranc's amputations." 

Tarso-metatarsal Amputation (Lisfranc's). The in- 
cision for this amputation is a curved one carried across 
the dorsum of the foot from the base of the fifth to the 
base of the first metatarsal bone (Fig. 406, A). The in- 
cision should involve the skin only, its centre lying half 
an inch or more below the centre of the line of the articu- 
lations, and it should begin and end at the sides of the 
foot at their junction with the sole. A plantar flap should 
be marked out by a curved incision crossing the sole of 
the foot near the origin of the toes, starting and ending at 
the same points as the dorsal incision. 

The dorsal flap is next dissected back to the line of the 
articulations; the tendons, muscular fibres, and fascia being 
divided, the joints between the tarsal and metatarsal bones 
are opened with a stout, narrow-bladed knife (Fig. 407). 
Difficulty is sometimes experienced in opening the joint 
between the head of the second metatarsal bone and the 
second cuneiform bone, which occupies a position higher 
on the foot than the other articulations. The disarticu- 
lation may also be facilitated by forcibly depressing the 
anterior portion of the foot. After all the joints have 
been opened, the knife is passed behind the ends of the 
metatarsal bones, and a plantar flap is cut from within 



486 AMPUTATIONS. 

outward, following the line of the incision previously 
marked out. The plantar flap may be cut from without 
inward if preferred. 

Fig. 407. 




Amputation at the tarsometatarsal joint. (Lisfranc's.) 

Tarso -metatarsal Amputation (Hey's). The line of 
incision and the steps of this operation are similar to 
those in Lisfranc's amputation, with the exception that 
Hey sawed off the projecting portion of the internal cunei- 
form bone after disarticulating the metatarsal bones. This 
modification, although it improves the appearance of the 
stump, possesses no advantages over the previous procedure. 

Medio-tarsal Amputation (Chopart's). In this ampu- 
tation the disarticulation is through the joints formed by 
the astragalus and calcaneum behind and the scaphoid and 
cuboid in front. An incision is made from the tubercle 
of the scaphoid across the dorsum of the foot an inch in 
front of the head of the astragalus to the lower and outer 
border of the cuboid (Fig. 406, B). The plantar flap is 
next marked out by an incision beginning and ending at 
the same points as the first incision and crossing the sole 
of the foot four or five finger-breadths nearer the toes 



SUBASTBAGALOID AMPUTATION. 



487 



(Fig. 408, A). The dorsal flap is next dissected up, and 
after the tendons and fascia have been divided the joint 



Fig. 408. 




Lines of incision for— A. Chopart's amputation. B. Syme's amputation. D. 
Section of bone in Syme's amputation. C. Subastragaloid amputation. (Stimson. ) 



is opened and a plantar flap is cut from within outward, 
following the line of the previously marked-out plantar 
incision (Fig. 409). 

FTn. 409 




Chopart's amputation. (Bryant.) 



Subastragaloid Amputation. In this amputation all 
the bones of the foot are removed except the astragalus. 



488 



AMPUTATIONS. 



An incision is made, beginning an inch below the tip of 
the external malleolus, which is carried forward to the 
base of the fifth metatarsal bone; it is then carried over 
the dorsum of the foot to the calcaneo-cuboid articulation 
(Fig. 408, Q). The joints between the scaphoid and 
astragalus and between the astragalus and os calcis are 
opened, and the latter bone is carefully dissected out; 
the ligaments are divided and the astragalus only is 
allowed to remain in place. 

Amputations at the Ankle-joint. 

Syme's Amputation at the Ankle-joint. In this am- 
putation, the foot being at a right angle to the leg, an 

Fig. 410. 




Syme's amputation at the ankle-joint. (Skey.) 

incision is made from the centre of one malleolus directly 
across the sole of the foot to the centre of the opposite 
malleolus (Fig. 408, B). The tissues of the heel are 



AMPUTATIONS AT THE ANKLE-JOINT 



489 



next carefully dissected from the bone by keeping the 
knife close to the osseous surface until the tuberosity of 
the os calcis is fairly turned (Fig. 410). The two extrem- 
ities of the first incision are then joined by a transverse 
one across the instep, and, the joint being opened, the 
lateral ligaments are divided to complete the disarticula 
tion. The knife is next used to clear the malleoli, and 
they are next removed by the saw in the line indicated 
(Fig. 408, D). 

Pirogoff's Amputation at the Ankle-joint. In this 
amputation the posterior portion of the os calcis is re- 
tained. The incision is carried from the tip of the inner 



Fig. 411. 




Pirogoff's amputation. A. Cutaneous incision. B. Line of section of bones. 
(Stimson.) 

malleolus, over the instep, half an inch in front of the 
anterior edge of the tibia, to a point half an inch in front 
of the tip of the outer malleolus; a second incision, cross- 
ing the sole of the foot and carried down to the bone, is 
next made (Fig. 411, A). The plantar flap is dissected 
back for a quarter of an inch, the joint is opened by 
dividing the lateral ligaments, and the astragalus is dis- 
articulated, and the malleoli are exposed. A narrow saw 
is next applied to the upper and posterior part of the cal- 



490 



AMPUTATIONS. 



caneum behind the astragalus, and it is divided obliquely 
downward in the line of the plantar incision (Fig. 412). 
The malleoli and a thin slice of the tibia are next removed 
with the saw, as in Syme's amputation (Fig. 411, B). 
Some surgeons do not remove the malleoli but press the 
sawed surface of the os calcis between them when it is 

Fig. 412. 




Application of saw to os calcis in Pirogoff 's amputation. (Ebichsen.) 



possible to do so. The position of the os calcis in relation 
to the tibia after union has occurred is shown in Fig. 413. 
Roux's Amputation at the Ankle-joint. In this 
method of amputation an incision is made at the outer 
edge of the tendo-Achillis, a little above its insertion, 
which is carried forward under the outer malleolus, and 
across the instep half an inch in front of the anterior 
edge of the tibia, and back to a point just in front of 
the inner malleolus; the incision is carried from this 
point downward and partly across the sole of the foot, 
and then back to the point of origin of the orginal in- 
cision (Fig. 414). The flaps are dissected up for a short 
distance, the ankle-joint is then opened, the disarticula- 



AMPUTATIONS AT THE ANKLE-JOINT. 



491 



tion is effected, and the internal flap is carefully dissected 
from the bones. 

Fig. 413. 








Union between calcaneum and tibia in Pirogoft's amputation. (Hewson.) 
Fig. 414. 




Incision in Roux's amputation. 



Other methods of amputation of the foot are sometimes 
employed, such, for instance, as that advocated by Han- 
cock, who has combined PirogofPs amputation with the 
subastragaloid method, bringing the sawed surface of the 



492 AMPUTATIONS. 

os calcis in contact with a transverse section of the astrag- 
alus. 

Hancock has advocated the propriety of amputating in 
the foot without regard to the position of the tarsal joints, 
cutting the flaps of sufficient length and dividing the bones 
with a saw. 

Tripier has also modified the subastragaloid amputation 
by leaving the upper part of the calcaneurn, which he 
saws through on a level with the sustentaculum tali, and 
at right angles to the axis of the leg; the external incisions 
are made as in Chopart's amputation. 

In the method advocated by Mikulicz the astragalus and 
calcaneum are removed, the ends of the tibia and fibula 
are sawed off, and the sawed surfaces of the scaphoid and 
cuboid are approximated to these, the stump resulting 
resembling the foot of pes equinus. 

Amputations of the Leg. 

The leg may be amputated at its lower, middle, or upper 
third, the rule being to save as much of the limb as pos- 
sible; but as regards the application of prosthetic apparatus, 
I think the stumps resulting from amputations in the 
middle and upper thirds will be found more satisfactory. 
It is well also in sawing the bones to divide the fibula at 
a slightly higher point than the tibia. 

The leg may be amputated by the circular, modified 
circular, oval, elliptical, long anterior flap, rectangu- 
lar flap, antero-posterior flap, lateral flap, or external flap 
methods. 

Circular Method. A circular incision is made through 
the skin and connective tissue just above the malleoli, and 
the cuff is dissected up for a sufficient distance, and a cir- 
cular incision of the tendons and muscles is next made, 
and the tissues being retracted, the bones are divided with 
a saw. 

Modified Circular Method. In this method of ampu- 
tation of the leg a circular incision of the skin and con- 
nective tissue and two short lateral incisions are made. 



AMPUTATIONS OF THE LEG. 



493 



The flaps are then dissected up to the ends of the incisions, 
and a circular division of the muscles is next made (Fig. 
415, A). 



Fig. 415. 



Fig. 416. 





Fig. 415.— Amputation of the leg. A. Modified circular method. B. Rectangu- 
lar flap. C Antero-posterior flap. The dotted lines indicate the levels at which 
the bones are to be sawn through. (Stimson.) 

Fig. 416.— Amputation of the leg. A. Long anterior flap. B. Elliptical flap. 
C. At upper third. (Stimson.) 



494 



AMPUTATIONS. 



Oval Method. Oval skin flaps are made and dissected 
up and the tissues are next divided down to the bone 
by a circular incision and the bones are divided with a 

saw (Fig. 417). 

Fig. 417. 




Oval skin flaps with circular division of the muscles. (Bryant. 



Elliptical Method. In this method of amputation the 
incision is in the form of an ellipse; its lower end crosses 
the heel below the insertion of the tendo-Achillis, and the 
upper end of the incision is about an inch above the ante- 
rior articular edge of the tibia (Fig. 416, B). 

Long Anterior Flap Method. An anterior flap equal 
in length to the diameter of the leg at its base is marked 
out by a curved incision through the skin beginning at 
the posterior edge of the tibia on the inner side, a little 
below the point at which the bones are to be divided, and 
is carried over the leg to a point directly opposite over the 
fibula (Fig. 416, A). The anterior muscles are divided 
transversely half an inch above the lower end of the flap 
and are dissected from the bone to the base of the flap. 

The posterior flap is then made by entering the knife 
behind the bones at the point of the original incision and 
cutting directly outward. 

Long Anterior Rectangular Flap Method (Teale). 
In this method of amputation of the leg an incision 
equal in length to half of the circumference of the leg 
is made from the point at which the bones are to be 
divided on one side of the leg, and is carried across the 
limb and back upon the opposite side to a point opposite 
the point of starting. The flap thus marked out is dis- 
sected up to its base, and a posterior flap of one-fourth the 



AMPUTATIONS OF THE LEG. 495 

length is next cut by a transverse incision down to the 
bones, and is dissected back to the line of the origin of 
the first incision (Fig. 415, B). The long flap is next 
doubled back and its edges secured to the posterior flap, 
or the long flap may be cut from the posterior surface of 
the leg and the short flap from the anterior surface. 

Antero posterior Flap Method. A long anterior flap, 
including half of the circumference of the limb, may be 
cut from without inward, composed of skin, connective 
tissue, and muscles, and a short posterior flap, cut from 
within outward, may also be employed. This method is 
often employed in amputations in the upper portion of the 
leg (Fig. 415, 0). 

Lateral Flap Method. In the lower and middle thirds 
of the leg the method of amputation by means of lateral 
skin flaps may be employed with advantage. In this 
method an incision is made over the spine of the tibia, 
and an oval flap, embracing one-half of the circumference 
of the leg, composed of the skin and connective tissue, is 
dissected up; starting from the same point a similar flap 
is formed on the opposite side of the leg and dissected up; 
the muscles at the upper extremity of the flaps are next 
divided by a circular incision and the bones are divided 
with a saw. 

External Flap Method (Sedillot). In this method of 
amputation of the leg the point of the knife is entered a 
finger's breadth external to the spine of the tibia and 
carried outward, grazing the fibula, and is brought out 
as far as possible to the inner side; a flap three or four 
inches in length is then cut from within outward ; the 
extremities of the incision are next united by an incision 
across the inner side of the limb involving the skin only; 
auy remaining muscular tissue is next divided and the 
bones are sawed. The long external flap is then brought 
over the ends of the bones and fastened to the edges of the 
incision on the inner side of the limb. Prof. Ashhurst 
modifies this operation by cutting the long external flap 
from without inward, and makes also a short internal flap 
in the same manner. By either method the resulting 



496 A MP U T A TIONS. 

stump is a good one, with the ends of the bones covered 
by the tissues of the external flap. 

Amputations at the Knee-joint. 

Amputations at the knee-joint may be done either by 
the circular or elliptical incision, or by means of flaps, 
and may consist in simple disarticulations or sections 
through the condyles of the femur. 

Elliptical or Oval Method. In this operation an in- 
cision crossing the spine of the tibia, five finger-breadths 
below the lower extremity of the patella, is carried 
around the back of the leg three finger-breadths higher 
than in front; the tissues on the front of the leg are dis- 
sected up until the tendon of the patella is exposed; the 
leg is then flexed and the ligament of the patella is 
divided; the capsular ligament and the lateral and cru- 
cial ligaments are next severed, care being taken not to 
injure the popliteal vessels with the point of the knife. 
The tibia is next drawn forward and the knife is passed 
behind its posterior border, and the remaining soft parts 
are divided from within outward. 

Anterior Flap Method In this method of amputation 
a long cutaneous flap is formed; the incision beginning 
half an inch below the articulation is carried five inches 
below the patella; crossing the anterior surface of the leg 
it is carried back to the condyle of the femur on the oppo- 
site side. This flap is dissected up and the ligament of 
the patella is divided, and the disarticulation is effected. 
A short posterior flap, uniting the anterior incision one 
inch below its extremities, is next cut by transfixion or 
from without inward (Fig. 418, A). The patella is not 
removed. 

Amputation Through the Condyles of the Femur. 
In this amputation, which is known as Carden's ampu- 
tation, an anterior flap, whose lower extremity is three 
finger-breadths below the patella, is cut and the disarticu- 
lation is effected, and the posterior soft parts are divided. 
The patella is removed, and the condyles next sawed 



AMPUTATIONS AT THE KNEE-JOINT 



497 



through just above the edge of the articular cartilage 
(Fig. 418, B). 

Lateral Flap Method. In this operation an incision 
is made just below the patella, which is carried down the 



Fig. 4 IS. 




Amputations at the knee-joint and lower third of the thigh. A. Long anterior 
flap. B. Amputation through condyles. B'. Line of section of the condyles of 
the femur. C. Modified flap at lower third of thigh. (Stimson.) 



spine of the tibia for three inches, and is then carried 
backward to the middle of the leg at a point opposite the 
beginning of the incision; a similar flap is cut on the 
opposite side of the leg, and the flaps are dissected up to 

32 



498 



AMPUTATIONS. 



the line of the articulation. When this point is reached 
the joint is opened and the disarticulation is effected. The 
patella is not removed (Fig. 419). 



Fig. 419. 




Amputation at the knee-joint by lateral flaps. (Smith.) 

Gritti's Amputation of the Knee-joint. In this opera- 
tion a long rectangular anterior flap is first cut and dis- 
sected up, and after the disarticulation has been effected 
the skin covering the posterior surface of the knee is cut 
from within outward. The condyles of the femur are 
next removed by a saw above the edge of the articular 
cartilage, and the articular surface of the patella is removed 
by the saw or cutting forceps. The patella is next brought 
down, so that its sawed surface is in contact with the sawed 
surface of the condyles, and the flaps are brought together 
(Fig. 420, A). 

Amputations of the Thigh. 

Modified Flap Method. Two semilunar flaps of skin 
and connective tissue, the upper extremities of which are 
several inches above the condyles of the femur, are cut 
and dissected up, and the muscles are next divided by a 
circular incision, and the bone is cut through with the saw 
(Fig. 418, C). 

Long Anterior Flap Method. In this operation an 
incision is made on the anterior aspect of the thigh, 
marking out a flap whose length is equal to one-third, 



AMPUTATIONS OF THE THIGH. 



499 



and whose width at its base is equal to two-thirds, of the 
circumference of the limb. The anterior muscles are 



Fig. 420. 




A. Gritti's amputation at the knee. A'. Lines of division of the hones. B. 
Amputation of the thigh, long anterior flap. B'. Division of the hone. C. Am- 
putation at the lower third of the thigh. C. Division of the bone. D. Disarticu- 
lation at the hip-joint. (Stimson ) 



next divided obliquely upward and backward , so that the 
flap shall not be too thick, and the posterior muscles are 



500 AMPUTATIONS. 

cut transversely and the bone is divided with a saw (Fig. 
420, B). 

Amputation in the lower third of the thigh may also be 
effected by employing a long anterior and short posterior 
flap. The anterior flap is cut, its lower extremity extend- 
ing down to the lower edge of the patella, and after dis- 
secting up the skin and cellular tissue to the upper 
extremity of the patella, the muscles are cut obliquely up 
to the point at which the bone is to be divided. A short 
posterior flap is next cut, and the soft parts being retracted, 
the bone is sawed through (Fig. 420, C). 

Amputation of the Thigh by Transfixion. In ampu- 
tations of the thigh the flaps may also be cut by transfixion, 
either lateral or antero-posterior flaps being employed 
(Fig. 421). 

Fig. 421. 




Amputatiou of thigh by flaps cut by transfixion. 

Amputation of the Thigh through the Trochanters. 
When, for any reason, it is inadvisable to amputate at 
the hip-joint, an amputation may be made through the 
trochanters, a long anterior and short posterior flap being 
employed, with a circular division of the muscles. 



AMPUTATIONS AT THE HIP- JOINT. 



501 



Amputations at the Hip-joint. 

In amputations at the hip-joint it is important that 
provision be made for the control of hemorrhage during 
the operation, and this is accomplished by the use of an 
abdominal tourniquet (Fig. 422), or by compression of 

Fig. 422. 




Abdominal tourniquet. 



the femoral artery by the fingers of an assistant, or by the 
preliminary ligation of the femoral artery just below 
Poupart's ligament. Esmarch's elastic strap may also 
be employed for the control of bleeding during amputa- 
tion at the hip-joint, the strap being applied in such a 
manner that it occupies the postion of the turns of a 
spica-bandage of the groin (Fig. 423). 

Dieffenbach and Wyeth, to avoid hemorrhage, make 
first a circular amputation in the continuity of the thigh, 
and after controlling the hemorrhage disarticulate the head 
of the femur and remove it; Jordan and Semi disarticulate 
the head of the bone first through an external incision and 
control the bleeding before the amputation is completed 



502 AMPUTATIONS. 

by passing an elastic tourniquet around the soft parls 
above the point where they are to be divided. 

Fig. 422. 




Esmarch's elastic strap applied to control hemorrhage during amputation 
at the hip-joint. 

The methods of amputation at the hip-joint are the 
oval, antero-posterior flap and lateral flap, and modified 
circular methods. 

Oval Method. This is performed by entering the point 
of a strong knife into the tissues below the anterior supe- 
rior spinous process of the ilium and making two oblique 
incisions, one forward and downward and the other back- 
ward, both incisions meeting on a transverse line on the 
inner side of the thigh. The muscles are next divided on 
a little higher line, and when the joint is exposed disarticu- 
lation is effected from the outer side and any remaining 
tissue is divided. 

Antero-posterior Flap Method. In this method the 
point of a long amputating knife is thrust into the tissues 
about two finger-breadths below the anterior superior 
spinous process of the ilium, and is pushed through the 
tissues grazing the hip-joint, and is brought out on the 
opposite side of the thigh close to the junction of the 
scrotum. The knife is next carried downward close to 
the bone, and an anterior flap of sufficient length is cut 



AMPUTATIONS AT THE HIP-JOINT. 



503 



from within outward. This flap is held up by an assist- 
ant aud the head of the bone is disarticulated, and the 
knife being passed behind the bone, a posterior flap of 
equal length is cut from within outward (Fig. 424). 



Fig. 424. 




Amputation at the hip-joint by antero-posterior flaps. (Holmes. 



Guthrie' s method of amputation at the hip-joint consists 
in cutting the flaps from without inward, a smaller knife 
being used for this purpose and the posterior flap being 
cut first. 

Modified Circular Method. In this operation short 
antero-posterior flaps of skin and connective tissue are 
cut and dissected up, and the muscles are divided by a 
circular incision on the level of the joint, and the disar- 
ticulation of the head of the femur is next effected. 

Lateral Flap Method. In this operation two flaps are 
cut from the inner and outer side of the thigh by trans- 
fixing, or by cutting from without inward and exposing 



504 AMPUTATIONS. 

the joint, which is opened and the disarticulation of the 
head of the femur is effected as in the previous methods 
(Fig. 425). 

FTG. 425. 




Amputation at the hip-joint by external and internal flaps. (Bryant.) 

Wyeth's Method of Controlling Hemorrhage in Amputating 
at the Hip-joint. In amputating at the hip-joint by this 
method the hip to be operated upon is brought well over 
the edge of the table and an Esmarch bandage is applied 
to the limb, and two stout steel pins, twelve or fourteen 
inches in length, are required; the point of one of these 
pins is passed through the skin one and a half inches 
below and slightly to the inner side of the anterior supe- 
rior spine of the ilium and carried through the tissues 
about half-way between the great trochanter and the spine 
of the ilium external to the neck of the femur, and its 
point is made to emerge just behind the trochanter; the 
second pin is made to enter the skin an inch below the 
crotch, internal to the saphenous opening, and its point is 
made to emerge about an inch and a half in front of the 
tuber ischii. The points of the pins are next protected 
with corks, and a long piece of rubber tubing or an Es- 
march elastic strap is wound tightly five or six times 
about the limb above the fixation pins (Fig. 426). The 
Esmarch bandage should then be removed and a cir- 
cular incision of the skin and cellular tissue should be 
made five inches below the constricting band; this cellulo- 
cutaneous cuff should next be reflected to the level of the 
trochanter minor; a circular division of all the muscles 



AMPUTATIONS AT THE HIP JOINT 



505 



should next be made at this point and the bone divided 
with a saw. The large vessels should next Joe secured, 



Fig. 426. 




Pius inserted and tube applied. 
Fig. 427. 




Limb amputated and bone sawed. (Wyeth.) 



506 AMPUTATIONS. 

and after this has been done the rubber tube should be 
removed and any vessels which bleed should be tied. 
The exposed end of the femur is then grasped with bone 
forceps, and an incision is next made upon the outer side 
through the skin and muscles until the neck and head of 
the bone are exposed, and the disarticulation is accom- 
plished. Wyeth now practises disarticulation of the head 
of the femur in this amputation without first sawing the 
bone; the circular method or antero-posterior flaps may 
be employed to expose the head of the bone. 



PAET VII. 

EXCISIONS OR RESECTIONS. 



EXCISION OF THE JOINTS. 

This implies th'e partial or complete removal of the 
articular surface of the bones making up the joint. The 
term resection is sometimes used as synonymous with 
excision, but is usually employed to indicate the removal 
of a portion or the whole of the shaft of one of the long 
bones. Excisions or resections of joints and bones may 
be required on account of injury, disease, or anchylosis of 
a joint in faulty position. In the operation of excision 
of the joint the incision should be free enough to permit 
of an inspection of the diseased portions of the joint, and 
it is preferable to remove the diseased articular surface of 
the bone with a saw; small areas of diseased bone may be 
removed with the curette or gouge forceps. In perform- 
ing excisions of joints in young subjects care should be 
taken to see that the epiphyseal cartilage is not encroached 
upon, for if this is removed the subsequent growth of the 
limb is interfered with. The result desired in cases of 
excision of joints, in addition to the removal of the dis- 
eased tissue, varies somewhat with the joint iuvolved; for 
instance, in a knee-joint anchylosis is desired; in the shoul- 
der, hip, elbow, and wrist, we wish to obtain a movable 
false joint; when the latter condition is desired after ex- 
cision, care should be exercised not to divide muscles or 
tendons, and as far as possible not to interfere with their 
attachments. When anchylosis is desired the division of 



508 



EXCISIONS OR RESECTIONS. 



muscles or tendons is not a serious consideration; any in- 
jury to the principal arteries, veins, and nerves should 
always be avoided. 

Fig. 428. 




Fig. 429. 




Butcher's saw 






Fig. 430. 



Narrow-bladed saw. 
Fig. 431. 




Chain saw. 



The instruments required for the excision of joints are 
a stout scalpel (Fig. 428), probe-pointed knife, and ex- 



INSTRUMENTS FOR EXCISION. 509 

Fig. 432. 




Lion-jawed forceps. 
Fig. 433. 




Fig. 434. 



Elevator. 
Fig. 435. 




B one-cutting pliers. 
Fig. 436. 




Knife-bladed forceps. 



Fig. 437. 




Periosteotome. 



510 EXCISIONS OR RESECTIONS. 

cision saw with reversible blade (Fig. 429). narrow -bladed 
saw (Fig. 430), or chain saw (Fig. 431), strong lion-jawed 
forceps (Fig. 432), retractors (Fig. 433), an elevator (Fig. 
434), heavy bone-cutting pliers (Fig. 435), knife-bladed 
forceps (Fig. 436), and a periosteotorae (Fig. 437). 

Excision of the Shoulder-joint. In excising the 
shoulder-joint the arm is adducted and rotated inward, 
and a straight incision is made extending from the beak of 
the coracoid process down the arm in the line of the bicipital 
groove; this incision may be supplemented by a short, 

Fig. 438. 




Excision of shoulder-joint : A. Regular incision. B. Supplementary. (Stimson.) 

transverse incision from the upper edge of the first incision 
to the acromion process (Fig. 438). As the incision is 
deepened the fibres of the deltoid muscle are divided in this 
line, and the capsule of the joint is exposed and divided 
along the outer edge of the tendon of the long head of the 
biceps muscle; this tendon is held to one side and the cap- 
sule of the joint is freely opened, and the muscles inserted 
into the tuberosities of the humerus are divided with a 
probe-pointed knife and freed with an elevator; the head 
of the bone can then be removed by sawing across the 
surgical neck of the bone with a narrow metacarpal saw 
or chain-saw, and the sawed surface of the humerus should 
then be rounded off with bone pliers. If upon examina- 



EXCISION OF THE ELBOW-JOINT. 511 

tion the glenoid cavity is found to be diseased, this with 
the neck of the scapula may be removed with gouge for- 
ceps or a small saw. The bone is then reduced and the 
wound is drained and closed. 

Resection of the Humerus. The whole or a portion 
of the humerus may require resection for injury or disease. 
The incision should be made upon the outer side of the 
bone and carried down in the muscular interspaces on a 
line with the shaft, care being taken to avoid injury of 
the musculospiral nerve, which, as it passes around the 
posterior surface of the humerus, lies close to the bone be- 
tween the humeral heads of the triceps muscle at a point cor- 
responding to the deltoid insertion anteriorly — i. e. y about 
the centre of the shaft of the humerus. This nerve should 
be isolated and held aside and the bone should be exposed. 
After separating the periosteum as completely as possible, 
if the shaft of the bone is diseased, it should be removed 
by dividing it in the middle with a saw or forceps, and 
removing each fragment as far as the upper and lower 
epiphysis, or the upper or lower portion onJy may require 
removal In resecting the humerus for an ununited frac- 
ture the incision is made upon the outer surface of the arm 
over the seat of fracture, and when the latter has been 
exposed the fragments are separated, and the end of each 
fragment is removed with a saw, to obtain a fresh bone 
surface. The freshened ends of the bone are then drilled 
and united by heavy silver-wire sutures, silver plates, or 
screws. 

Excision of the Elbow-joint. In excising the elbow- 
joint, the forearm is slightly flexed and a longitudinal inci- 
sion is begun about two inches above the olecranon process 
and a little to its inner side, and carried about three or 
four inches down in the line of the ulna (Fig. 439); the 
tissues are then divided down to the bones and the ulnar 
nerve is dissected from its groove behind the inner con- 
dyle of the humerus and held aside by a retractor; the 
tendon of the triceps is divided and its attachment to the 
fascia and periosteum over the olecranon process is sepa- 
rated with an elevator or periosteotome and turned down- 



512 



EXCISIONS OB RESECTIONS. 



ward; the joint is next opened and the lateral ligaments 
are divided as the forearm is flexed upon the arm. The 
upper part of the ulna and the head of the radius are 
freed with a probe-pointed knife and are removed with a 
narrow-bladed saw, care being taken in making the section 



Fig. 439. 



1 1\ I 
// 

Ik i i 
; I ; i 
! 1/ i i 

Incision for excision of the elbow-joint. (Stimson.) 

of the radius to divide its neck so that the attachment of 
the biceps muscle is not interfered with. The condyles 
of the humerus are next freed and removed with a saw. 
In freeing the bones at the anterior portion of the joint 
great care should be used to avoid injury of the brachial 
artery and vein and the median nerve. 

Resection of the Radius and Ulna. The radius or 
ulna may be resected either entirely or partially by making 
an incision over the bone to be removed upon the back of 
the forearm; the bone being exposed, the periosteum is 
separated with an elevator and the bone is divided with 
a saw, and each fragment is lifted and separated from its 
muscular attachments up to the point where it is desired 
to remove it (Fig. 440). If the articular surface of the 
bone is to be removed the disarticulation should be made 



EXCISION OF THE WRIST. 



513 



carefully with a strong scalpel or a probe-pointed knife, 
care being taken to avoid injury of the vessels and nerves 
lying upon its palmar surface. 



Fig. 440. 




Resection of the lower end of the radius. 
Fig. 441. 




Articulations of the wrist-joint. (Lister.) 

Excision of the Wrist. The wrist is covered on its 
posterior and lateral aspects with skin, fascia, and tendons; 

33 



514 



EXCISIONS OR RESECTIONS. 



the relative position of the bones entering into the articu- 
lation can be seen in the accompanying figure (Fig. 441). 
The wrist-joint may be excised by making a dorsal inci- 
sion, which begins at the middle of the ulnar border of 
the second metacarpal bone, and is carried upward about 
four inches, crossing the ulnar edge of the tendon of the 
extensor carpi-radialis-brevior, and splitting the dorsal 
ligaments of the wrist between the tendons of the extensor 
secondi-internodii and the extensor of the forefinger (Fig. 
442). The incision should be carried down to the bone 

Fig. 442. 




Incision for excision of wrist-joint. (Stimson. 



and the soft parts and tendons should be dissected loose with 
an elevator. By flexing the hand the first row of the carpus 
is made to present in the wound, and the scaphoid is sepa- 
rated from the trapezium and removed; the semilunar and 
cuneiform should next be removed ; the trapezium and 
pisiform should be left if possible. In removing the 
second row of carpal bones the knife should be passed 
between the trapezium and trapezoid and then into the 
carpo-metacarpal joint, and by cutting the ligaments on 



METACARPOPHALANGEAL JOINTS. 



515 



the dorsal side of the ends of the metacarpal bones the 
trapezoid, os magnum, and unciform can then be removed. 

The lateral ligaments are next carefully divided and 
the articular ends of the radius and ulna removed with a 
saw; the ends of the metacarpal bones should next be 
removed with a saw or cutting pliers. 

Resection of a Metacarpal Bone. A metacarpal bone 
may be resected by making a longitudinal incision on the 
back of the hand over the bone to be removed. The in- 
cision should extend from one articular end to the other, 
and the extensor tendon when exposed should be held to 
one side by retractors; the periosteum should next be 
separated as far as possible, and when the bone has been 



Fig. 443. 




Resection of metacarpal bone. 

fully exposed it may be removed by dividing it in the 
middle with bone-cutting pliers and then disarticulating 
each fragment; or the articular ends may be freed and 
the bone removed in one piece (Fig. 443). 

Excision of Metacarpophalangeal Joints or Inter- 
phalangeal Joints. In excising a metacarpophalangeal 
joint the joint is exposed by a longitudinal incision over 
the dorsal surface of the knuckle; the extensor tendon 
being exposed and held to one side, the lateral ligaments 



516 



EXCISIONS OB RESECTIONS. 



are divided. The articular ends of the bones are then 
exposed and removed with a metacarpal saw or with bone- 
cutting pliers (Fig. 444). In excising the interphalangeal 



Fig. 444. 




Excision of a metacarpophalangeal joint. 

joints the incision is usually made upon the side of the 
joint, and when the articular surfaces of the bone have been 
exposed they are removed with a small saw or cutting 
pliers. 

Fig. 445. 




Resection of the sternal end of the clavicle. 



Excision of the Clavicle. The clavicle is excised by 
making an incision over the bone from one articulation to 



RESECTION OF THE STERNUM. 5 17 

the other, which is carried directly down to the bone; the 
periosteum is then separated and the shaft of the bone may 
be divided at the middle and each fragment raised and 
disarticulated; or the bone may be disarticulated at one 
extremity, then raised up and freed from its adherent 
tissues and disarticulated at the other extremity. In 
disarticulating the sternal articulation of the clavicle 
(Fig. 445) a probe-pointed knife should be used, and 
great care should be exercised to avoid injury of the 
important vessels and nerves which lie in close proximity 
to it. 

Resection of the Ribs. In resecting a rib the incision 
should correspond in length and direction with the portion 
of bone to be removed, and may be crossed at each end by 
a short transverse incision. The tissues overlying the rib 
are then dissected loose, the periosteum is separated as far 
as possible, and the rib is divided by cutting-pliers at two 
points, and the piece is grasped with forceps and the at- 
tachments to the under surface of the rib are separated 
with an elevator. Care should be taken to avoid opening 
the pleural cavity. 

Estlander's Operation. This operation is employed in 
cases of empyema, and consists in resecting the portions 
of several adjoining ribs to allow the chest-wall to sink 
inward and unite with the pulmonary pleura. The inci- 
sion is made along the intercostal space occupied by the 
fistula and the adjoining ribs as far as it may be necessary. 
To resect them a rectangular or oval flap, including all of 
the tissues external to the ribs, is made and dissected up, 
and portions of several ribs are divided with bone-cutting 
pliers and removed with forceps. If the costal pleura is 
very thick, to expose the cavity so as to permit of free 
drainage and allow the chest- wall to sink in it may be cut 
away over a part of the area from which the ribs have 
been resected; one to four inches of three to six adjoining 
ribs may be removed. 

Resection of the Sternum. Eesection of the sternum 
is performed by making a longitudinal incision over the 
portion of the bone to be removed; the periosteum is sepa- 



518 



EXCISIONS OB RESECTIONS. 



rated, and the diseased portion of the sternum is then 
carefully freed with an elevator and removed. 

Excision of the Scapula. To excise this bone an 
incision should be made along the whole length of the 
spine of the scapula, and from its posterior extremity 
two other incisions should be made, one running about an 
inch or two above, and the other passing down the poste- 
rior border of the bone to its inferior angle (Fig. 446); 

Fig. 446. 




Incision for excision of scapula. (Stimson.) 



the flaps thus made are loosened by separating the muscles 
attached to the outer surface of the bone. The attach- 
ments of the deltoid and trapezius muscles to the acromion 
and spine of the scapula are separated, and the lower angle 
is freed by detaching the teres major and serratus magnus. 
The bone is then raised, and the subscapulars muscle is 
detached from below upward. The neck of the scapula 
should be divided with a chain-saw or cutting forceps; 
the acromion is next separated from the clavicle and the 
scapula turned upward, the joint being opened from below. 



EXCISION OF THE HIP-JOINT 



519 



The coracoid process should be separated from its muscular 
and ligamentous attachments, or may be divided with a 
saw and left in place. In clearing the supraspinous fossa 
care should be taken not to injure the suprascapular nerve 
in the suprascapular notch; it should be raised with the 
periosteum and its fibrous sheath. 

Excision of the Hip. In excising the hip-joint a curved 
or angular incision is made from a point about three inches 
below the crest of the ilium, and about the same distance 

Fig. 447. 




Incisions tor excision oi' the hip-joint. (Stimson. 



behind the anterior superior spine of the ilium, which 
should be carried downward over the great trochanter in 
the line of the femur for about five or six inches (Fig. 
447); the soft parts are dissected from the great trochanter 
and upper part of the sheath of the femur, and the cap- 
sule of the joint is opened. An assistant should next 



520 EXCISIONS OB RESECTIONS. 

rotate the thigh inward and outward, and with a blunt- 
pointed knife the muscles attached to the trochanters are 
shaved off close to the bone; the neck of the femur is 
next freed by the use of a knife and elevator; the thigh 
is adducted and pushed upward, and the head and neck of 
the bone are made to project from the wound. A trans- 
verse section of the bone is then made with a saw just 
below the great trochanter. In some cases it is difficult 
to remove the head of the bone, which may be anchylosed 
firmly to the acetabulum; here the bone may first be divided 
with a chain- saw passed around the femur just below the 
great trochanter, or may be divided with a chisel, the head 
and neck of the bone afterward being removed with gouge 
or bone-cutting pliers. After the head and neck of the 
bone have been removed the acetabulum is examined, and 
if it is found to be diseased the diseased tissues should be 
removed with a curette, gouge, and forceps. 

Anterior Excision of the Hip. In this method of excising 
the hip-joint an incision is made upon the front of the 
thigh over the joint, beginning half an inch below the 
anterior superior spine of the ilium, and is carried three 
or four inches downward and a little inward; as the inci- 
sion is deepened the tensor vagina femoris and the glutei 
muscles are exposed, and should be drawn to the outer 
side, and the sartorius and rectus muscles are held to the 
inner side and the neck of the femur is exposed; the 
neck of the bone is then divided with a metacarpal saw 
or Adams' saw, and the diseased portion of the bone is 
next grasped with strong sequestrum forceps, and by the 
use of these and an elevator the head of the bone is re- 
moved; the acetabulum is then examined, and, if diseased, 
the diseased tissue is removed with gouge or curette. 

Excision of the Knee-joint. The knee-joint is excised 
by making an incision which begins at the inner side of 
the limb over the inner condyle of the femur, and is 
carried over the front of the knee just below the patella 
to a corresponding point upon the external condyle of the 
femur (Fig. 448, A), or by an angular incision (Fig. 448, B). 
The flap thus formed is dissected up to a point correspond- 



EXCISION OF THE KNEE-JOINT, 



521 



ing with the upper edge of the patella, the ligamentuni 
patella is then cut through, the leg is slightly flexed, and 
the joint is opened ; the lateral ligaments are then divided, 
and by flexing the leg upon the thigh the joint is freely 
exposed. The semilunar cartilages are next removed 
and the condyles of the femur are freed; a narrow-bladed 
saw is placed under the condyles and a transverse section 
of the condyles is removed; the head of the tibia is next 



Fjg. 448. 




Incision for excision of the knee-joint. A. Curved incision, 
incision. (Stimson.) 



B. Angular 



cleared and a transverse section of this bone is also re- 
moved with a saw. The patella may be removed before 
excising the ends of the bone, or, if anchylosed to the 
condyles, may be removed with the section of bone which 
removes a portion of the condyles. After sufficient bone 
has been removed, if localized areas of carious bone present 
themselves upon the sawed surface of the bones, they may 
be removed with a gouge or gouge forceps. In excising 
the knee-joint in young persons care should be taken to 
remove only so much bone as may be done without 



522 EXCISIONS OB RESECTIONS. 

encroaching upon the lines of epiphyseal cartilages, as 
removal of the epiphyseal cartilage would interfere with 
the subsequent growth of the bones. 

Arthrectomy of the Knee-joint. This operation is em- 
ployed as a substitute for the operation of excision in 
disease of the knee-joint, and is performed by exposing 
the joint by an incision similar to that employed in ex- 
cision; the ligamentum patella is divided and the patella 
is reflected with the skin flap. When the joint has been 
freely exposed the diseased articular cartilages, semilunar 
cartilages, crucial ligaments, and synovial pouches are re- 
moved by the use of the knife or scissors and the curette; 
if the surface of the bone is found to be carious, it is 
removed by the curette or gouge. After the joint has 
been thoroughly cleared of diseased tissue it is irrigated, 
and the divided ligamentum patella is sutured with sev- 
eral strands of chromicized catgut or silk, and the wound 
is drained and closed. 

Excision of the Patella. The patella may be excised 
by making a longitudinal or crucial incision; the perios- 
teum is carefully separated from the bone, and the latter 
is grasped with strong bone forceps and dissected free from 
its attachments upon the under surface. The knee-joint 
is generally opened in removing the patella, unless the 
removal of the bone be undertaken for necrosis or caries, 
when it is possible to accomplish its complete removal 
without opening the joint. 

Resection of the Tibia or Fibula. In resecting the 
tibia or fibula the bones may be exposed by a longitudinal 
incision over the bone to be removed, and after the shaft 
of the bone has been exposed and the periosteum sepa- 
rated as completely as possible, the shaft of the bone may 
be divided at its middle and each fragment grasped with 
forceps and dissected up, and removed at its epiphyseal 
junction (Fig. 449). 

Excision of the Ankle joint. In excising the ankle- 
joint an incision is made at a point two inches above the 
external malleolus, and carried downward over the fibula 
to the tip of the external malleolus; it is then curved 



EXCISION OF THE ANKLE-JOINT. 523 

Fig. 449. 




Resection of lower end of fibula. 
Fig. 450. 



\ 




Incision for excision of ankle-joint. (Stjmson.) 



524 EXCISIONS OR RESECTIONS. 

slightly upward toward the dorsum of the foot (Fig. 450), 
care being taken that the incision does not extend so far 
forward as to endanger the extensor tendons or the dorsal 
artery. The bone is exposed in this incision and the peri- 
osteum is separated and turned aside; the peroneal tendons 
are next exposed and held to one side by retractors; the 
external malleolus is next divided with bone-cutting pliers 
and removed, and the astragalus is exposed. The upper 
articulating surface of the astragalus is next removed with 
bone forceps or a saw, or the whole bone maybe removed. 
The foot is next inverted and the end of the tibia is cleared 
with a probe-pointed knife, care being taken not to injure 
the posterior tibial artery, nerve, or vein, and when the 
articular surface has been freed it is removed with a saw or 
bone-cutting pliers. The articular end of the tibia may be 
exposed by making an additional incision upon the inner 
side of the ankle over the internal malleolus if desired. 

Excision of the Astragalus. In excising the astragalus 
a semilunar incision is made upon the outside of the ankle- 
joint, very similar to that employed in excising the ankle; 
the external lateral ligaments are divided with a probe- 
pointed knife, and the astragalus is exposed by forcibly 
inverting the foot; the bone is then seized with strong 
forceps, and its ligamentous attachments are divided with 
a probe-pointed knife, and it is removed. 

Excision of the Os Calcis. An incision is made on 
the level of the upper part of the bone, beginning at the 
inner border of the tendo-Achilles, dividing this tendon 
and passing around the back and outer surface of the foot 
to the base of the fifth metatarsal bone; a short incision 
is then made at the anterior end of the first incision and 
carried down to the sole of the foot; the bone is exposed 
and held by forceps; the flap thus formed, which includes 
the peronei tendons, is then separated from the bone, and 
the cuboid ligaments are cut and also the interosseous 
ligament between the os calcis and the astragalus, and the 
bone is removed with forceps. 

Resection of the Metatarsal Bones. Any of the meta- 
tarsal bones may be resected by an incision on the dorsum 



EXCISION OF THE UPPER J A W. 525 

of the foot over the bone to be removed; the bone is ex- 
posed, the extensor tendons being held aside by retractors; 
the bone is disarticulated at either end or is cut in its 
middle and each fragment dissected np and removed at 
its articulation. The metatarsal bone of the great toe is 
exposed by making a curved incision over that bone on 
the inner side of the foot (Fig. 451). 

Fig. 451. 




Incision for the resection of the metatarsal bone of the great toe. (Smith.) 

Excision of the Coccyx. In excising the coccyx the 
finger is passed into the rectum and the position of the 
bone is determined; a longitudinal incision through the 
skin and fibrous tissues covering the coccyx is made from 
a point about a quarter of an inch above its upper limit, 
and is carried down to a little below its lower extremity. 
This incision may be supplemented with a transverse in- 
cision. The sacro-coccygeal articulation is then opened; 
an elevator is next introduced into the articulation and 
the bone is raised up and grasped with forceps. It should 
then be freed from its lateral attachments, and those upon 
its anterior surface, with the knife and elevator. 

Excision of the Upper Jaw. In excising one-half of 
the upper jaw the incision is begun half an inch below the 
inner canthus of the eye, and is carried downward along 
the line of junction of the nose and face, along the course 
which limits the alse nasi, and longitudinally to the septum, 
and then down through the free border of the lip; it is 
also advisable to carry the incision along the lower edge of 
the orbit upward over the malar bone (Fig. 452); the flap 
being dissected away from the surface of the bone, a small, 
narrow metacarpal saw is then applied to the floor of the 
nostril until a deep groove is made; the soft palate and 



526 



EXCISIONS OR RESECTIONS. 



the tissue covering the hard palate are next divided from 
within the mouth with a strong knife; one or two incisor 
teeth should be removed, and one blade of a pair of strong 
bone-cutting pliers is introduced into the floor of the nose in 
the line of the saw incision, the other is introduced into the 
mouth in the line of the division of the structures of the 

Fig. 452. 




Incision for excision of the upper jaw. 



palate, and the bone is divided. The malar bone is next 
divided with a saw or forceps, and, finally, the blades of a 
strong pair of bone-cutting forceps are introduced, one into 
the nostril and the other at the edge of the orbit, the impor- 
tant structures of the orbit being held upward with a 
retractor, and the inner angle of the orbit is cut across; 
the superior maxillary bone is then grasped with strong, 
lion-jawed forceps, and can be twisted out, any band of 
tissues which holds it being divided with the knife or 
scissors. 

Excision of the Lower Jaw. Partial or complete 
excision of the lower jaw may be practised. 

Excision of the Ramus and Half of the Body of the Lower 
Jaw. The incision should be made from a point just below 
the free border of the lip over the symphysis and carried 
down to the lower border of the jaw, and from this point it 



EXCISION OF THE LOWER JAW. 527 

is carried along the ramus to the lobe of the ear (Fig. 453) ; 
the flap is then dissected up, separating the masseter muscle 
from the bone as far as possible without opening the cavity 
of the mouth; an incisor tooth is next drawn and the bone 
is sawed through near the symphysis; the jaw is then seized 
with forceps and drawn downward and forward and de- 
nuded upon its inner surface. The insertion of the tem- 

FlG. 453. 




Incision for excision of the lower jaw. 

poral muscle into the coronoid process is divided, and the 
condyle of the jaw is disarticulated from the glenoid cavity, 
and the remaining soft parts are carefully detached with 
a knife or elevator. The facial artery and the inferior 
dental nerve and artery are necessarily divided in re- 
moving this portion of the jaw. 

Partial Excision of the Lower Jaw or Alveolus. The re- 
moval of a portion of the alveolar process of the jaw may 
often be accomplished through the month without the aid 
of a cutaneous incision. The condyle of the jaw may be 
excised by making an incision close in front of the tem- 
poral artery and carrying it forward along the zygoma 
for an inch and a half; the tissues being divided and the 
bone exposed, a second incision involving only the skin is 



528 EXCISIONS OR RESECTIONS. 

then carried from the centre of the first directly down- 
ward for about an inch; the soft parts are next carefully 
separated with a knife and elevator from the margin of 
the zygoma and outer surface of the joint and drawn 
downward with a retractor, to prevent injury of the parotid 
gland, nerves, and vessels. The neck of the condyle is 
then cleared by working around it in front and behind 
with a director, keeping close to the bone to avoid injury 
of the internal maxillary artery. A chain-saw is then 
passed around the neck of the bone, which is divided, and 
the condyle is seized with forceps and removed with an 
elevator or gouge. 

TREPHINING THE SKULL. 

This is an operation in which a circular disk of bone of 
the skull is removed by a circular saw or trephine to ex- 

FlG. 454 




Trephine. 

pose the membranes and the brain. If a wound is already 
present in the scalp, exposing the skull, as in the case of 
compound fracture of the skull, it is exposed and bared, 
so that the crown of the trephine can be placed fairly on 
the bone; if no wound exists a U-shaped flap is made, 
including all the structures down to the bone. The base 
of the flap should be so situated as to contain a sufficient 
blood-supply, and the flap should be so planned as to favor 
drainage from the wound. When the bone has been ex- 



TREPHINING THE SKULL. 



529 



posed the trephine is placed with the centre pin projecting 
about one-sixteenth of an inch, and the instrument is turned 
from right to left until a groove is made in the bone; the 
trephine is then removed, and the centre pin is raised so 
that as the teeth of the trephine approach the inner table 
of the skull the point of the centre pin will not injure the 
membranes or brain. The instrument is then reapplied 
and worked cautiously as the groove in the bone is deep- 

Fig. 455. 




1. Trephine opening for mastoid antrum. 2. For abscess from otitis media. 3. 
To expose cerebellum. 4-5. For middle meningeal hemorrhage. A. Lateral 
sinus. B. and C. Limit of up and down variation. (Stimson.) 



ened. When the diploe is reached there is usually some 
bleeding from the wound, and as the trephine approaches 
the inner table of the skull it should be manipulated with 

34 



530 OSTEOPLASTIC RESECTION OF SKULL. 

great care, and when the resistance is felt to diminish at 
any one part of the bone the trephine is made to cut at 
other points of the bone where the resistance is still appar- 
ent. When the disk is completely cut through it can be 
lifted out in the crown of the trephine or can be removed 
with forceps or an elevator. If the opening in the skull 
has to be enlarged to obtain greater exposure of the mem- 
branes or brain it can be done very satisfactorily with a 
form of rongeur forceps. 

A portion of the skull may also be removed by the use 
of the gouge and mallet; the gouge is generally preferred 
to the trephine in opening the mastoid cells. 

When the trephine is applied to expose hemorrhage from 
the middle meningeal artery, or hemorrhage from the lat- 
eral sinus, or an abscess from middle-ear disease, or to open 
the mastoid antrum, the positions for the application of 
the trephine are indicated in Fig. 455. 

Osteoplastic Resection of the Skull. In this opera- 
tion for exposing the membranes of the brain, a portion of 
the skull having the soft parts attached is turned aside, 
so that it can subsequently be replaced and sutured in its 
original position. A horseshoe-shaped incision is made, 
and the edges are allowed to retract (Fig. 456). A groove 
is next cut through the bone, following the line to which 
the skin flap has retracted, with a chisel or with a circular 
saw run by a dental engine or electro-motor. The line of 
division of the bone should be oblique, so that the outer 
table of the flap shall rest upon the inner table of the 
skull when the bone flap is turned back into place. The 
base of the bone flap is then partly divided with the chisel, 
with as little disturbance of the soft parts as possible, and 
the remaining bone in the base of the flap is broken and 
the flap turned back, the scalp acting as a hinge (Fig. 
457). 

GigWs wire saw may be used in operating upon the 
skull. Two small trephine openings are made and a flat 
director passed into one of the openings, to separate the 
dura on a line between them, and the wire saw drawn 
through this space by a thread attached to a flexible silver 



OSTEOPLASTIC RESECTION OF SKULL. 

Ftg. 456. 



531 




Fig. 457. 




Osteoplastic resection of the skull. (After Tkeves.) 



532 LAMINECTOMY. 

probe. The bridge of bone is then divided by the saw. 
Any desired amount of bone can be removed by making 
three or four trephine openings and sawing between them. 

If the osteoplastic flap method is employed the skin is 
left undivided on one side and adherent to the bone flap, 
and the saw is made to cut the bridge of bone between the 
trephine openings obliquely, so as to bevel the edges of the 
flap. 

Trephining the Antrum of Highmore. The antrum 
may be opened by extracting the first or second molar 
tooth and deepening its socket with a small gouge or bone 
drill. 

The antrum may also be opened through the mouth, to 
avoid a scar upon the face, by the use of a small trephine 
or bone gouge; the gingivo-labial fold is divided up to a 
point just below the infra-orbital foramen, the trephine 
is placed here and a disk of bone removed, opening the 
antrum. 

Trephining the Frontal Sinus. This sinus may be 
opened by a trephine or bone gouge. An incision is made 
from the centre of the supra-orbital ridge to the median 
line above the root of the nose. The tissues are divided 
down to the periosteum ; this is incised and turned aside, 
and the trephine or gouge is placed at the centre of the 
incision near the inner edge of the supra-orbital ridge and 
a disk of bone is removed, exposing the frontal sinus. 

LAMINECTOMY. 

This operation, which consists in exposing and cutting 
away the arches of the vertebrae, to secure a free exposure 
of the spinal canal and cord, is resorted to in cases of 
fracture of the vertebrae, tumors of the spinal cord, and in 
cases of tuberculosis of the spine in which there is marked 
deformity with paralysis, the object being, as a rule, to 
relieve the spinal cord from pressure. A straight incision, 
four or five inches in length, is made over the point at 
which the arches of the vertebrae are to be removed, and 
the skin, muscles, and fascia are divided, and the spinous 



OPERA TIONS UPON NEB VES. 533 

processes and arches of the vertebrae are laid bare. Then 
with strong bone-cutting forceps the arches of the vertebrae 
on each side are divided, care being taken to avoid in- 
juring the dura. A better method is the formation of a 
lateral flap by an incision over the arches upon one side, 
the periosteum and muscles being reflected to the base of 
the spinous processes, the latter then being divided with 
bone forceps or chisel and lifted up in the flap, the dissec- 
tion of which is continued toward the other side until the 
arches are exposed from end to end. The latter are then 
cut away. It is often necessary to remove several laminse 
if any considerable amount of the spinal cord or canal is 
to be exposed. 

OPERATIONS UPON NERVES. 

Neurotomy. Neurotomy is an operation in which the 
nerve-trunk is exposed and a section made through the 
nerve. As in the case of ligation of vessels, it is most 
important that the operator should have an accurate knowl- 
edge of the anatomical relations of the nerves and the sur- 
rounding structures. The nerve is exposed by an incision 
similar to that for the exposure of an artery for the appli- 
cation of a ligature. 

Nerve-stretching, Neurectasy, or Neurotony. In the 
operation of neurectasy, or stretching of nerves, the nerve 
is exposed and isolated and is lifted upon a blunt hook or 
retractor; or, in the case of the larger nerves, is hooked out 
of the wound by the finger, and is thoroughly stretched 
and replaced in the wound and the latter is closed with 
sutures. 

Neurectomy. In this operation the nerve is exposed 
and a portion of the nerve is excised. 

Suture of Nerves or Neurorrhaphy. In bringing into 
apposition the ends of divided nerves primary or secondary 
sutures may be employed. The material employed for 
sutures should be fine silk or fine chromicized catgut. 

In using primary sutures the suture in the case of the 
smaller nerves should be passed through the sheath and 



534 



OPERATIONS UPON NERVES. 



substance of the nerve, and in the larger nerves two sets 
of sutures can be used, one passing through the substance 
of the nerve the other being passed through the sheath. 

Nerve-grafting. In employing secondary sutures to 
unite the divided ends of nerves when there has been a 
loss of substance in the nerve, or there has been so much 
retraction of the nerve that it is impossible to bring the 
ends together, nerve-grafting may be made use of; the 
ends of the nerve being freshened, a section of a fresh 
nerve from an amputated limb or animal is sutured to 



Fig. 458. 



Nerve-grafting. (Willard.) 



the ends of the divided nerve to fill up the gap, as seen 
in Fig. 458. 

Neuroplasty. Another method of lengthening the ends 
of the divided nerve, known as neuroplasty, may be em- 
ployed where the ends cannot be brought into apposition 
by the ordinary method; in this method flaps are made 
for the nerve in the same way as in the lengthening of 



Fig. 459. 



Neuroplasty. (Willard.) 



shortened tendons, and the ends of the flaps are sutured 
together, as seen in Fig. 459. Sutures a distance may 
also be employed, as in the case of the separated ends of 
tendons (p. 544). 

The following incisions are given to expose the nerves 
for some of these various operations : 

The Supra-orbital Nerve. This nerve is exposed at the 
supra-orbital notch at the junction of the middle and inner 
thirds of the supra-orbital arch. An incision is made one 



OPERATIONS UPON NERVES. 535 

and a half inches in length, parallel to the eyebrow (Fig. 
460, A and B), and is carried down to the bone; the nerve 
is exposed and grasped with forceps, and resected or 
stretched as may be desired. 



A and B. Incisions for resection of supra-orbital nerve. C. Incision for resection 
of the superior maxillary nerve. 

The Superior Maxillary Nerve. A vertical incision is 
made along the inner side of the nose from the bony 
ridge of the nasal process of the superior maxillary bone 
to the ala of the nose; a second incision is begun at the 
upper part of this incision and carried outward along the 
lower margin of the orbit beyond its centre (Fig. 460, C); 
the lower flap is dissected up and the nerve is exposed. 
The upper flap is next lifted up with the lower eyelid and 
eyeball, exposing the floor of the orbit, and the infra-orbital 
canal can be recognized running backward and inward; the 
canal is opened with a knife or chisel, and the nerve is 
separated from the artery and cut off as far back as may 
be necessary. The nerve may also be reached by exposing 
the anterior wall of the antrum, and trephining this and 
the posterior wall, and, w T hen found, may be cut off close 
to the exit of the main trunk from the round foramen in 
the sphenoid bone. 

The Inferior Dental Nerve. To expose this nerve, an 
incision is made along the lower jaw, from a point just 



536 



OPERATIONS UPON NERVES. 



behind the angle, and carried forward to a point just in 
front of the edge of the masseter muscle; the periosteum 
and masseter muscle are then separated from the bone 
with an elevator, and the inferior dental canal may be 
opened with a small trephine or chisel; the exposed nerve 
is then raised upon a hook and resected. 

The Lingual Nerve. The lingual nerve can be felt just 
behind the attachment of the pterygo-maxillary ligament, 
on the inner side of the lower jaw, close to the bone, below 
the last molar tooth; the tongue should be drawn to one 
side and the mucous membrane divided for an inch, par- 
allel to the alveolar process, beginning at the last molar 
tooth; the nerve is then found in the submucous tissue. 

The Facial Nerve. This nerve may be exposed at the 
posterior border of the ramus of the jaw by an incision 



Fig. 461. 




Resection of the brachial plexus. 



extending from just in front of the tragus of the ear to the 
angle of the jaw. The parotid fascia is divided and the 
cervico-facial branch may be exposed first, and can be fol- 
lowed back to its junction with the temporo-facial branch. 



OPERATIONS UPON NERVES. 537 

The Brachial Plexus. The brachial plexus consists of 
the four lower cervical nerves and the greater part of the 
first dorsal; it lies between the anterior and middle scaleni 
muscles and crosses the floor of the subclavian triangle at 
the base of the neck. To expose the brachial plexus the 
neck and head are extended and the face is turned toward 
the opposite side; an incision is made half an inch above 
the clavicle, between the sterno-cleido-mastoid and trape- 
zius muscles, and is carried forward for about three inches 
parallel to the anterior border of the trapezius. The skin 
and platysma are divided, and the external jugular vein 
is either cut and ligatured or held to one side ; the deep 
cervical fascia is next opened in the line of the external 
incision, and the outer border of the anterior scalene 
muscle is felt for; the brachial plexus is found just out- 
side the latter, and is exposed by careful dissection (Fig. 
461). 

The Spinal Accessory Nerve. To expose the spinal acces- 
sory nerve, an incision about three inches in length is made 
downward from the tip of the mastoid process along the 
anterior border of the sterno-mastoid muscle; the cervical 
fascia should be divided and the muscle strongly retracted, 
to put the nerve on the stretch. The nerve should be 
found external to the jugular vein, about an inch and a 
half below the tip of the mastoid process, on the fascia 
covering the rectus capitis anticus major. 

The Median Nerve. The median nerve may be exposed 
at the bend of the elbow or just above the wrist. To 
expose the median nerve at the bend of the elbow an 
incision is made about an inch and a half in length upon 
the inner edge of the biceps tendon ; the bicipital fascia is 
divided and the nerve is exposed at the inner side of the 
brachial artery. The median nerve may also be exposed 
above the wrist by an incision two inches in length along 
the inner border of the tendon of the palmaris longus 
muscle. 

The Ulnar and Radial Nerves. These nerves may be ex- 
posed by an incision similar to that employed for ligation 
of the ulnar or radial artery. 



538 OPERATIONS UPON TENDONS. 

The Musculo-spiral Nerve. The musculo-spiral nerve is 
exposed by an incision on the outer side of the arm above 
the elbow, from the upper part of the supinator groove; 
the fascia being divided, the nerve is sought for at the 
bottom of this groove. 

The Great Sciatic Nerve. To expose the great sciatic 
nerve, an incision three or four inches in length is made 
vertically downward from the gluteal fold at a point mid- 
way between the tuberosity of the ischium and the great 
trochanter; the skin and fascia being divided, the lower 
border of the gluteus maximus and the hamstring muscles 
are exposed; the nerve rests on the external rotators of 
the thigh just in front of the outer side of the hamstring 
muscles. 

The Internal Popliteal Nerve. This nerve is exposed by 
an incision two inches in length in the middle of the pop- 
liteal space. The nerve is slightly external to the vein 
and artery, and is more superficially placed. 

The External Popliteal Nerve. This nerve is exposed by 
an incision two inches in length, parallel and close to the 
inner side of the biceps tendon, and lies close behind and 
to the inner side of the tendon of the biceps muscle. 

The Anterior Crural Nerve. This nerve is exposed by 
an incision about two inches in length, extending from 
Poupart's ligament downward, and about an inch to the 
outer side of the femoral artery. 

OPERATIONS UPON TENDONS. 

Tenotomy. This is an operation which consists in the 
division of a tendon, and it may be done subcutaneously 

Fig. 462. 



Sharp-pointed tenotome. 

or by an open operation. The former method of tenotomy 
is to be preferred in most cases, but in certain tendons 



OPERATIONS UPON TENDONS. 539 

which lie in close proximity to important vessels and 
nerves it is safer to employ the open operation. In 
dividing tendons the parts should be placed in such a posi- 
tion as to put the tendon upon the stretch. The instru- 
ments required are a sharp and a blunt-pointed tenotome. 
The sharp-pointed tenotome (Fig. 462) is used to make 
a puncture down to the edge of the tendon, being entered 
flatwise; it is then withdrawn and a blunt-pointed tenotome 
(Fig. 463) is introduced through the puncture, passed under 




Blunt-pointed tenotomes. 

the tendon, and turned so that the tendon rests upon its 
cutting edge; by a gentle rocking motion the tendon is 
then divided, and the tenotome should be turned flatwise 
and withdrawn. 

The Tendo-Achillis. In dividing this tendon, a sharp- 
pointed tenotome should be entered at the inner border 

Fig. 464. 




Tenotomy of tendo-Achillis. 



of the tendon about an inch above its attachment to the 
calcaneum (Fig. 464); the heel should be depressed as 
much as possible, so as to make the tendon prominent, 
and the sharp-pointed tenotome should be passed through 
the skin and behind the tendon; this is next removed and 



540 OPERATIONS UPON TENDONS. 

a blunt-pointed tenotome is introduced and the tendon is 
divided. The posterior tibial artery, nerve, and vein lie 
to the inner side, and are not likely to be injured if the 
tendon is divided from this point. 

The Posterior Tibial Tendon. This tendon may be divided 
above the inner malleolus. The muscle is made tense by 
everting the foot, and the tenotome is entered at the inner 
side of the tendon and passed behind it. The posterior 
tibial tendon may also be divided upon the side of the 
foot; for this operation the foot is everted and the teno- 
tome is passed from above downward and passed under the 
upper border of the tendon at a point half an inch below 
and in front of the tip of the internal malleolus. 

The Anterior Tibial Tendon. This tendon is divided upon 
the dorsal surface of the foot, just below the annular liga- 
ment of the ankle, midway between the two malleoli. 

The Peroneal Tendons. The peroneal tendons may be 
divided about an inch above the external malleolus, the 
tenotome being passed from before backward between the 
fibula and the tendons, or the tendons may be divided at 
a point midway between the end of the external malleolus 
and the tubercle of the cuboid. 

The Hamstring Tendons. The inner hamstring consists 
of the tendons of the semi -tendinous, semi-membranosus, 
gracilis, and sartorius. The external hamstring consists 
of the tendon of the biceps. To divide either of these 
tendons the knife is entered at the inner side of the tendon. 
In dividing the external hamstring care should be taken 
to keep close to the tendon of the biceps, as the external 
popliteal nerve lies close to its inner border. 

The Adductor Longus. To divide this tendon, abduct the 
thigh and make the muscle prominent near its insertion; 
then pass the tenotome from without downward and in- 
ward. 

The Flexor Longus Pollicis. This tendon may be divided 
on the first phalanx or near the inner edge of the foot, 
where it may be made prominent by strong extension of 
the great toe, the tenotome being passed close to the border 
of the tendon. 



OPERATIONS UPON TENDONS. 541 

The Extensor Longus Digitorum. These tendons are 
divided upon the dorsal surface of the metatarsal bones, 
where they are quite prominent. They may also be 
divided near the ankle. 

The Extensor Proprius Pollicis. This tendon may be 
divided in the same incision used for division of the long 
flexor of the toes, the point of the knife being carried 
inward. 

The Sterno-cleido-mastoid Muscle. In tenotomy of this 
muscle, the sternal and clavicular attachments are divided 
about an inch above the sternum and clavicle. A puncture 
is made to the outer side of the muscle with a sharp teno- 
tome, and when the tendinous expansion of the muscle is 
reached it is withdrawn, and a blunt tenotome is substi- 

FlG. 465. 




Tenotomy of sterno-mastoid. 

tuted for it and the structure is divided. The sternal 
attachment is divided through a separate puncture in the 
same way. The external jugular vein is to be avoided at 
the outer border of the muscle. The division of the 
muscle, or its tendinous expansion by an open operation, 
is now very often practised, as there is less risk of injur- 
ing the vein by this procedure. 



542 



OPERATIONS UPON TENDONS. 



Suture of Tendons. In bringing together the divided 
ends of tendons primary or secondary sutures are em- 
ployed; primary sutures are those introduced immediately 
after the injury, and secondary sutures are those intro- 
duced after retraction of the ends has occurred and the 
wound has healed. 

Primary Suture of Tendons. The material employed for 
sutures may be silk, silkworm-gut, catgut, or kangaroo- 
tendon, and one or more sutures may be employed, being 
passed through the substance of the ends of the tendon 

Fig. 466. 




Suture passed through the substance of the ends of divided tendon. 



and secured by tying; the divided sheath of the tendon, 
if possible, should be brought together by fine silk sutures 
(Fig. 466). Very marked retraction of the ends of the 
tendon is apt to occur, and a considerable dissection is 
often required to bring them into view. 

Fig. 467. 




Tendon-suture which does not easily tear out. (Stimson.) 



When there is difficulty in bringing the ends of the 
tendon together, and the sutures are apt to cut out, the 
form of suture shown in Fig. 467 may be employed. 



OPERATIONS UPON TENDONS. 



543 



Secondary Suture of Tendons. In apply id g secondary 
sutures to tendons, the principal difficulty is often encoun- 
tered in bringing the ends of the tendon in contact and 
in holding them successfully in this position. The ends 
of the tendon have first to be freshened, and this may be 
done by cutting them obliquely and introducing a suture 
as shown in Fig. 468. This method of section presents 
a large raw surface of the tendon for union. 



Fig. 468. 




Oblique section of ends of tendon to increase surface of contact. (Stimson.) 

Lengthening of Tendons. When so large a gap exists be- 
tween the ends of the tendon that they cannot be brought 
into apposition, a plastic operation may be performed upon 
their ends, which often overcomes the difficulty. This 

Fig. 469. 




Lengthening of retracted tendon by flaps. (Stimson.) 



consists in making a section half-way through the tendons, 
at some distance from their ends, and splitting them toward 
their divided extremities, and then turning out these flaps 
and securing their ends by means of sutures (Fig. 469). 



544 TRACHEOTOMY. 

When the ends of the tendon are so widely separated that 
they cannot be approximated, sutures a distance may be 
employed. These consist of sutures of sterilized silk or 
chromicized catgut passed between the ends of the tendons 
and tied, the sutures acting as a scaffolding upon which 
reparative material forms between the separated ends of 
the tendons. 

REMOVAL OF THE BREAST. 

This may be accomplished by making a circular incision 
around the breast, or by an incision starting at the ante- 
rior edge of the axilla and carried around the breast and 
brought back to the point of starting. The incision is 
deepened and the muscles are exposed, and the breast is 
dissected free from the muscles and removed. The axilla 
is next opened and any enlarged glands are removed. 
The modern operation of removal of the breast for malig- 
nant disease is one which is similar to that employed by 
Kocher and Halsted, and consists in removal of the breast, 
with the pectoral muscles and the axillary glands and 
connective tissue, the incision being very extensive, and 
extended so as to permit of the removal of glands situated 
above the clavicle. 

TRACHEOTOMY. 

This operation consists in dividing the tissues over the 
trachea in the median line of the neck, and after the trachea 
has been exposed it is opened by dividing two or three of 
the tracheal rings. 

The ease with which the operation is performed varies 
much in different cases; it is, as a rule, a much simpler 
operation in adults than in children. In the latter sub- 
jects the shortness of the neck, the relatively greater size 
of the thyroid gland, and the possible presence of the 
thymus body, the great vascularity of the parts, and the 
abundance of adipose tissue, render the trachea difficult to 
expose and open. 



TRACHEOTOMY. 545 

Under certain circumstances the operation may be per- 
formed with very few instruments; but if the surgeon has 
the choice he will find it convenient to have at hand two 
small scalpels, one short grooved director, a tenaculum, 
two aneurism needles, which may be used as retractors, 
one pair of artery forceps, haemostatic forceps, two pairs 
of dissecting forceps, a pair of scissors, a sharp-pointed 
tenotome, a pair of tracheal forceps, a tracheal dilator, 
tracheotomy tubes, tapes, ligatures, sponges, a flexible 
catheter, and feathers. The director should be short; the 
ordinary grooved director is too long to use with satisfac- 
tion in operating upon the short necks of children; so that 
I use a shorter and somewhat broader one, which has a 
bevelled extremity, which allows it to be passed with ease 
between the different layers of the tissues (Fig. 470). 

Fig. 470. 




Author's tracheotomy director. 

Hcernostatic jorceps are also of great use in controlling 
hemorrhage during the operation in case of the division 
of vessels which bleed freely, when the operator from the 
urgency of the case does not think it justifiable to ligature 
them at the time of their division. They may also be 
employed under similar circumstances to clamp the isth- 
mus of the thyroid gland on either side of the trachea when 
it becomes necessary to divide it to expose the trachea. 

A sharp-pointed tenotome is the instrument I prefer to 
employ in opening the trachea, as its sharp point enables it 
to be easily thrust into the trachea, and its short cutting 
surface and the narrowness of the blade obscure as little as 
possible the line of incision, and thus enable the operator 
to see exactly where he is cutting. 

Tracheal dilators of various kinds are employed, but the 
most satisfactory tracheal dilator which I have employed 

35 



546 



TRACHEOTOMY. 



is that of Golding-Bird (Fig. 471), which is a self-retain- 
ing instrument; the blades are slipped through the tracheal 
incision and are then expanded by turning the screw to 
which they are attached. 



Fig. 471. 



Fig. 472. 





Golding-Bird's tracheal dilator. 



Trousseau's tracheal dilator. 



Trousseau's tracheal dilator, the blades of which are 
introduced through the incision in the trachea and are 
expanded by bringing together the handles, is also a satis- 
factory instrument (Fig. 472), but is not so useful as the 
tracheal dilator previously mentioned, as it has to be 
retained in position by the hand. Tracheal dilators may 
be improvised from bent hair-pins or pieces of wire, which 
will often serve a useful purpose where ordinary dilators 
cannot be obtained. 

It is also well to have at hand a number of pliable feathers 
to be used in cleaning the trachea or larynx of mucus or 
membrane after it has been opened, and by their use this 
object can be accomplished with little risk of injury to the 
mucous membrane. 



Fig. 473 




Tracheal forceps. 



Tracheal forceps, which are constructed with a double 
spring and curved blades, are also useful in removing 



TRACHEOTOMY. 



547 



membrane or foreign bodies from the larynx above the 
wound or from the trachea below the tracheal incision 
(Fig. 473). 

Tracheotomy -tubes of various shapes are made of silver, 
aluminum, hard and soft rubber, but the tube which I 
think is the most satisfactory for general use is a silver 
quarter-circle tube with a movable collar (Fig. 474), and 
provided with a fenestrated guide (Fig. 475). A good 



Fig. 474. 



Fig. 475. 





Silver tracheotomy-tube. 



Silver tracheotomy-tube with 
fenestrated guide. 



tracheotomy-tube is one which inflicts the least possible 
injury upon the mucous membrane of the trachea, and to 
insure this object the part of the tube within the trachea 
should lie exactly in its axis, and its free extremity should 
be capable of as little movement as possible. The trache- 
otomy-tube is held in position after being introduced by 
means of tapes attached to the shield of the tube and tied 
around the neck. 

Position of Patient for Tracheotomy. The best position in 
which to place the patient for this operation is that which 
brings the neck into the greatest prominence, and this can 
best be obtained by laying the patient upon his back upon 
a firm table and placing under the shoulders a round 
cushion; or an empty wine-bottle, or a roller-pin wrapped 



548 TRACHEOTOMY. 

in towels, will answer the same purpose (Fig. 476). If an 
anaesthetic is not used, the arms should be held by an 
assistant, which is better than securing them by a binder 
fastened around the chest, which restricts respiratory 
movements. 

Operation of Tracheotomy. The trachea may be 
opened above the isthmus of the thyroid gland or below 
it, and these operations constitute respectively the high 
and low operations. 

The high operation is generally selected, because at this 
point the trachea is more superficial and is more easily 
exposed, whereas in the low operation the trachea is more 
difficult to expose by reason of its relatively greater depth, 
the large size and number of the veins, and its proximity 
to the large arterial trunks. 

The patient being placed in position, and the best posi- 
tion is secured by placing a firm pad under the shoulders, 
or the head may be dropped over the edge of the table, 

Fig. 476. 




Position of patient for tracheotomy. 



the object being to secure a free exposure of the neck 
and to render the trachea as superficial as possible. The 
operator stands at the head of the patient; this posi- 
tion I prefer, as it is easier from this point to keep the 



TRACHEOTOMY. 549 

incisions exactly in the median line of the neck. The 
operator next makes hiraself familiar with the landmarks 
of the neck; locating the position of the cricoid cartilage, 
he makes an incision through the skin in the median line 
of the neck from one and a half to two inches in length, 
the position of the cricoid cartilage being the middle 
point. There is no disadvantage in making a longer in- 
cision if a freer exposure of the parts is required. Having 
divided the skin, the operator will often see a large vein 
lying in the superficial fascia — the superficial anterior jugu- 
lar ; this should be displaced and the fascia divided upon 
the director. 

The surgeon should keep his incisions strictly in the 
median line of the neck, for this is the line of safety; and 
he should be careful, as the wound increases in depth, not 
to make the incisions too short, so that it becomes funnel- 
shaped. 

When the deep fascia is exposed it should be picked up 
and divided upon the director, and any large veins in the 
line of the wound should be carefully displaced, or, if this 
is impossible, they should be ligated on each side and then 
divided between the ligatures. 

The operator now looks for the intermuscular space be- 
tween the sterno-hyoid and the ster no-thyroid muscles, which 
can generally be found without difficulty, and the muscles 
are now separated in this line, with the handle of the knife 
or with the director, and the isthmus of the thyroid gland 
will be exposed. The muscles should now be held aside 
by retractors placed on either side. 

The operator should carefully explore the wound with 
the finger, to locate exactly the position of the trachea, 
and to ascertain, if possible, the presence of any anoma- 
lous arteries. 

The isthmus of the thyroid gland having been exposed, 
generally occupying a position over the first three tracheal 
rings, the gland will be found surrounded by a plexus of 
veins, which should be displaced with the director, or, if 
this is impossible, they should be ligated on each side and 
divided between the ligatures. The thyroid isthmus is next 



550 



TRACHEOTOMY. 



displaced upward or downward, according as the surgeon 
desires to open the trachea below or above this body. This 
is oflen done without difficulty, especially its upward dis- 
placement ; but when there is difficulty in displacing it 
downward, a procedure recommended by Bose may be em- 
ployed, which consists in making a transverse incision 
across the cricoid cartilage to divide the layer of fascia by 
which the isthmus is bound down; a director is then passed 
into this incision and the isthmus is gently depressed 
without difficulty. 

Having displaced the isthmus of the thyroid gland up- 
ward or downward, the trachea, yellowish-white in appear- 
ance, covered by the tracheal fascia, will be exposed; 
this fascia should next be thoroughly broken up with the 



Fig. 477. 




Opening the trachea. (Liston.) 



director or handle of the knife, so as to bare the trachea, 
and in doing this the operator can feel it crepitate under 
the finger from the suction of air drawn in with inspira- 
tion. The trachea is next fixed with a tenaculum, intro- 
duced into it a little to one side of the median line; an 
incision is made into it with a narrow knife from below 



LARYNGOTOMY. 551 

upward, from one-half to three-fourths of an inch in length 
(Fig. 477), care being taken to see that this incision is in 
the median line, for if the trachea be opened by a lateral 
incision the wound does not heal so promptly and the 
tracheotomy-tube does not fit well, and its lower extremity 
may cause injury to the mucous membrane of the trachea. 
If the wound be a deep one, after fixing the trachea with 
the tenaculum the operator may lift it slightly from its 
bed, thereby bringing it more prominently into view and 
making it more superficial in the wound, thus facilitating 
its opening. As soon as the incision is made into the 
trachea there is a gush of air from the wound in the 
trachea, mixed with blood or membrane; this should be 
wiped away with a sponge and a tracheal dilator should 
next be introduced and the trachea should be cleared of 
membrane, if it is present in the region of the wound, 
with a feather or with forceps. The tracheotomy-tube is 
next introduced, and is secured in position by tapes tied 
around the neck. 

If respiration has ceased, artificial respiration should be 
resorted to, or the use of a tube attached to a bellows, or 
Fell's apparatus, and these efforts should be continued for 
at least fifteen minutes, for I have seen resuscitation take 
place in patients who were apparently dead by a persistent 
employment of artificial respiration. 

Laryngotomy. In this operation an opening is made 
into the air-passages through the crico-thyroid mem- 
brane. It is a simple operation, and one which is prac- 
tically free from risk, and can, therefore, be performed 
much more rapidly and safely in urgent cases than tra- 
cheotomy. 

The patient being placed in the recumbent posture, with 
the shoulders slightly elevated and the head thrown back, 
to make the neck as prominent as possible, the surgeon 
feels for the prominence of the thyroid cartilage, and 
steadying the larynx between the finger and thumb of 
the left hand, he makes an incision in the median line 
over the centre of the thyroid cartilage and extending 
downward for an inch or an inch and a half. The skin 



552 LARYNGO-TRACHEOTOMY. 

and superficial fascia being divided, the fascia between the 
sterno-hyoid muscles and the areolar tissue is exposed and 
divided, and the crico-thyroid membrane is exposed. The 
knife is then passed transversely through the membrane 
into the larynx, care being taken that both that mem- 
brane and the mucous membrane which covers its inner 
surface are divided at the same time. As soon as the 
knife enters the cavity of the larynx blood and mucus 
will be forcibly expelled. 

The wound should be carefully enlarged and a tube 
introduced, which differs from the ordinary tracheotomy- 
tube in being slightly flattened; this is secured in posi- 
tion by tapes tied around the neck, as in the case of 
the ordinary tracheal tube. The only bleeding which is 
likely to occur is from the crico-thyroid arteries or veins, 
and if these cannot be avoided, and are divided in the 
operation, they should be temporarily secured by haemo- 
static forceps or ligatured, and if the case is not extremely 
urgent, all bleeding should be arrested before the crico- 
thyroid membrane is incised. 

Laryngo-tracheotomy. This operation consists in 
making an incision into the air-passages by dividing one 
or two of the upper rings of the trachea, the crico-tracheal 
membrane, the cricoid cartilage, and the crico-thyroid 
membrane. This operation is employed in cases where, 
from the age of the patient, the crico-thyroid space is too 
small to admit of a sufficient opening, or in those in which, 
for any reason, the surgeon does not deem it advisable to 
attempt to open the trachea lower down. The incision in 
the skin and superficial fascia of the neck is made in the 
same manner as in the operation of laryngotomy, but is 
carried a little further downward. It may be necessary 
to displace the isthmus of the thyroid gland downward to 
expose the upper portion of the trachea, and when the 
trachea is exposed the incision should be made through 
this and the cricoid cartilage from below upward. A 
tracheotomy-tube is introduced through the wound and 
secured by tapes tied around the neck. 



INTUBATION OF THE LARYNX. 



553 



INTUBATION OF THE LARYNX. 

This procedure, at the present time, is widely employed 
as a substitute for tracheotomy in the treatment of dyspnoea 
due to inflammatory affections of the larynx or trachea, or 



Fig. 478. 




Mouth 



stenosis of the larynx; it consists in the introduction of 
a metallic or hard rubber tube into the larynx, which is 



Fig. 479. 




>> 



Intubation-tube and introducer. 



allowed to remain in place for a few days. The operation 
has been recently reintroduced to the profession by the 



554 



INTUBATION OF THE LARYNX. 



late Dr. O'Dwyer, of New York, who devised a set of 
ingenious instruments for the purpose of laryngeal intu- 
bation. 

The instruments required are a mouth-gag (Fig. 478), 
with which the jaws are separated and held open; an in- 



FlG. 480. 




Intubation-tube extractor. 



strument for the introduction of the tube, which is fastened 
to the obturator, which fills the cavity of the tube (Fig. 
479), and an instrument for extracting the tube after it 
has been placed in the larynx (Fig. 480). The tubes are 



Fig. 481. 




Scale of intubation-tubes. 



of metal or hard rubber, and have a collar which rests 
upon the false cords and bulge slightly toward their 



INTUBATION OF THE LARYNX. 555 

middle and again taper toward their lower extremity; at 
the collar of the tube there is a perforation through which 
a strand of silk is passed which is made into a loop; this 
is used to allow the operator to remove the tube if on its 
introduction it is found to have passed into the oesophagus 
instead of the larynx, and also is used to remove the tube 
if it becomes occluded with membrane while in the larynx. 
The intubation set now in common use is provided with a 
scale of seven tubes, ranging in size from such as are suited 
for a child of one year or less up to the age of twelve or 
fourteen years (Fig. 481). 

Operation of Intubation of the Larynx. In perform- 
ing the operation of intubation of the larynx, the child is 
placed upon the lap of the nurse or assistant, wrapped in 
a blanket, and the arms are secured by the nurse holding 
the elbows so as not to interfere with the respiratory move- 
ments. The patient's head is next secured by an assistant, 
and the position of the head, neck, and body should be as 
if he were hung from the top of the head, and this position 
should be firmly maintained during the insertion of the 
tube. The mouth-gag is next inserted upon the left side 
and the blades dilated so as to open the jaws widely, and 
as the gag is self-retaining, this position is easily main- 
tained. The jaws being thus held open, the operator, 
sitting on a chair facing the patient (Fig. 482), next in- 
troduces the index finger of the left hand, protected by a 
strip of adhesive plaster or a metal shield, into the mouth 
and passes it over the tongue until he feels the epiglottis. 
The introducing-instrument, to which the tube is attached, 
is held in the right hand, and this is now introduced into 
the mouth, first seeing that the silken loop is free, and it 
is swept over the tongue and passed down until it touches 
the epiglottis; this is hooked up by the index finger of 
the left hand and the tube is passed into the larynx; the 
index finger of the left hand is then transferred to the edge 
of the tube, and by pressing upon the trigger of the instru- 
ment with the thumb of the right hand the obturator 
is detached and the instrument is withdrawn, and before 
removing the finger it is well to place it upon the head of 



556 



INTUBATION OF THE LARYNX. 



the tube and to sink it well into the larynx. As soon as 
the obturator is removed there is usually a violent expira- 
tory effort, which is accompanied by a gush of mucus, 
mucopurulent matter, or membrane from the tube, and 



Fig. 482. 




Intubation of the larynx. 



after this escapes the breathing is usually satisfactorily 
established. If the operator has passed the tube into the 
oesophagus and has detached it from the introducing- 
instrument, no improvement in the respiration takes place; 
it should then be withdrawn by the silk loop and attached 
to the obturator, and another attempt should be made to 
introduce it into the larynx. 

The mistake which inexperienced operators make in 
attempting to introduce the tube is in not hugging the 



INTUBATION OF THE LARYNX. 557 

posterior surface of the tongue closely, so that they pass 
the tube over the epiglottis into the oesophagus. 

The silken loop may be brought out at one side of the 
mouth and adjusted around the ear or fastened to the side 
of the face by strips of adhesive plaster for a few hours, 
so that by drawing upon it the nurse or attendant is able 
to withdraw the tube instantly if it should become 
obstructed with membrane; or, if it is coughed up, by 
this means it may be withdrawn from the oesophagus if 
it has not been expelled from the mouth. Some operators 
keep the loop attached to the tube during the time it is 
retained in the larynx. I prefer to remove it after the 
tube is securely placed in the larynx and withdraw the tube 
by means of the extracting-instruinent when required. 
The tube is removed at the end of the second or third 
day, and if the child is able to breathe comfortably for 
an hour or two it is not reintroduced; if, however, the 
dyspnoea returns it is reintroduced and allowed to remain 
one or two days longer; several attempts may have to be 
made before the tube is permanently removed, but it is 
usually dispensed with from the third to the eighth day. 

The most serious complication which is apt to occur 
during the introduction of the intubation-tube is the 
detachment and pushing of a mass of membrane in front 
of the tube into the trachea; if this is too large to be ex- 
pelled through the tube the breathing is suddenly arrested. 
The tube should be removed at once, and if the mass of 
membrane does not escape upon the expiratory efforts of 
the patient, the trachea should be rapidly opened as the 
only means of re-establishing the respiratory function. So 
much do I dread this accident, which has occurred in a 
few cases, that I never introduce the intubation-tube with- 
out having at hand the necessary instruments to do a 
tracheotomy if it should be suddenly required, and, if 
possible, obtain the consent of the parents or friends to 
perform tracheotomy if it should be indicated. 

One of the greatest troubles after intubation of the 
larynx is the satisfactory feeding of the patient; liquids, 
as a rule, are not swallowed well, a portion of them 



558 



INTUBATION OF THE LARYNX. 



escaping into the tube, causing coughing and difficulty in 
breathing. The diet I usually order is of seini-solids, 
such as corn-starch, soft-boiled eggs, and mush; and if 



these are not well swallowed, it may be necessary to resort 



Fig. 483. 




Feeding a case of intubation of the larynx. 

to nutritious enemata or the use of a stomach-tube to in- 
troduce food. Some patients swallow liquids and semi- 
solids quite well if the head is dropped a little lower than 
the body during the act of deglutition (Fig. 483). 



OPERATIONS UPON THE KIDNEY. 

Nephrotomy. In this operation an incision is made 
into the kidney. The incision for exposure of the kidney 
is four inches in length, and should be made from a point 



OPERATIONS UPON THE COLON. 559 

two and a half inches from the spine, half an inch below 
the last rib and parallel with it. The latissimus dorsi, 
external and internal oblique, and transversalis muscles are 
divided, and the lumbar fascia is opened, exposing the peri- 
nephric fat; the kidney is then reached by displacing this. 

Lumbar Nephrectomy. The incision is the same as for 
nephrotomy, but the wound can be enlarged by another 
incision at right angles to the first, if more space is re- 
quired. After the kidney is exposed its capsule is incised, 
and the finger is passed around the organ to separate it 
freely from the capsule. When the ureter is recognized 
it is brought into view, ligatured, and cut off. The 
pedicle containing the vessels is next tied, and it is then 
divided in advance of the ligature with scissors, and the 
kiduey is removed. 

Abdominal Nephrectomy. To reach the kidney by 
abdominal incision, an incision four inches long is made at 
the outer border of the rectus muscle; the abdomen is 
opened and the viscera turned aside; the kidney is ex- 
posed and the capsule is opened; the ureter is ligated and 
the vessels are tied and the organ is removed, and a drain- 
age-tube may be introduced or the wound in the abdominal 
walls may be closed without drainage. 

Nephrorrhaphy. JSTephrorrhaphy is an operation in 
which the kidney is exposed through the same incision 
as that for nephrotomy, with the object of suturing a 
movable kidney fast in its normal position in the back; 
when the kidney has been reached a number of sutures 
are introduced into the capsule of the kidney, and secured 
to the fibrous and muscular tissue of the incision. Many 
surgeons prefer to omit the introduction of sutures and 
simply scarify the capsule of the kidney or dissect off a 
portion of the capsule, and then pack the wound with strips 
of gauze and allow the wound to heal by granulation. 

OPERATIONS UPON THE COLON. 

Lumbar Colostomy. In performing lumbar colotomy, 
or colostomy, on the left side, the patient should be placed 



560 INGUINAL COLOSTOMY. 

upon the right side, and a pillow should be placed under 
the loin to make the left side more prominent. An in- 
cision four inches in length is made midway between the 
last rib and the crest of the ilium, the centre of the inci- 
sion corresponding to the point midway between the ante- 
rior superior and posterior superior processes of the ilium; 
the tissues are divided to the full extent of the wound, 

Fig. 484. 




Incision in lumbar colotomy— dotted line shows situation of the colon. 
(Bryant.) 

until the lumbar fascia and edge of the quadratus lum- 
borum muscle have been reached; the former being cut 
through and the edge of the muscle divided, the bowel is 
exposed, when it is brought to the surface and fastened 
by sutures to the skin and subjacent tissues and opened. 

Inguinal Colostomy. In the operation of inguinal 
colostomy, an incision three inches in length is made on 
the left side parallel to and one inch above Poupart's 
ligament, with its centre on the level of the anterior supe- 
rior spine of the ilium, or a little lower; or, as practised 
by Ball, the colon may be exposed by an incision two 
and a half inches in length, following the line of the 
linea semilunaris, stopping just short of Poupart's liga- 
ment; the tissues are divided layer by layer and the peri- 
toneum is opened; the skin and parietal peritoneum may 
be united by a few sutures, and the gut is then brought 



REMOVAL OF THE APPENDIX VEBMIFOBMIS. 561 

out at the wound and fastened to its margins by fine 
sutures and is next opened. 

Maydl's Operation. In this operation the colon is ex- 
posed as in the previous operation, and then drawn out of 
the wound until its mesenteric attachment is on a level with 
the external incision. A sterilized glass rod or piece of 
catheter, or a roll of gauze three inches in length, is 
slipped through a slit in the mesocolon close to the gut. 



Fig. 485. 




Colon held in wound by glass rod. (Pilcher. 



This holds the intestine in the wound and prevents its re- 
turn to the abdominal cavity until adhesions have formed. 
The two limbs of the flexure of the gut exposed in the 
wound should be united by sutures beneath the support. 
If the gut is to be opened immediately it should be 
stitched to the parietal peritoneum of the abdominal 
incision. If the opening of the bowel can be postponed 
for twenty -four or forty-eight hours the introduction of 
sutures is not required. The bowel may be opened by a 
transverse incision with a knife, or by the ther mo-cautery, 
to avoid bleeding. 



REMOVAL OF THE APPENDIX VERMIFORMIS. 

To expose the appendix, an incision three to four inches 
in length at the outer border of the right rectus muscle is 
made, with its centre on a line drawn between the umbili- 
cus and the anterior superior spine of the ilium; the tissues 

36 



562 REMOVAL OF THE APPENDIX VERMIFOBMIS. 

are divided layer by layer and the peritoneum is picked 
up and opened; the anterior longitudinal band is recog- 
nized and traced down to its origin at the appendix. 
When the appendix is found the meso-appendix is liga- 
tured and the appendix is removed. In removing the 
appendix a circular incision may be made around it near 
its base, and the cuff may be turned back; the body of 
the appendix is then ligated, and the turned -back cuff is 
then brought forward and united by fine silk or catgut 
sutures. The appendix may also be ligated and cut off 

Fig. 486. 




Method of burying the stump of the appendix. (Richardson.) 



close to the gut or removed by cutting it off close to the 
gut and then inverting its stump into the colon, and sub- 
sequently suturing the walls of the colon together over the 
position of the stump of the appendix by a few Lembert 
sutures (Fig. 486). 

McBurney's Operation. When the appendix is removed 
for chronic cases of appendicitis this procedure may be 
employed with advantage. It consists in making the 
ordinary incision, and when the external oblique muscle 



LITHOTOMY. 



563 



is exposed its fibres are cut or separated in the direction 
of their length; the edges of the wound are next dilated, 
and the fibres of the internal oblique and transversalis 
muscles are separated in the same manner. After the 
operation is completed the fibres of the muscles may be 
sutured, and as they cross each other, firm support is given 
to the abdominal contents, and there is little chance of a 
hernia forming at the site of the incision. 

LITHOTOMY. 



Left Lateral Lithotomy. In performing this opera- 
tion, the patient is placed upon his back, the hands and 
feet are secured together, and the bladder is injected with 
a few ounces of boric solution. A grooved staff is intro- 
duced into the bladder, and the operator first passes one 
finger into the rectum, to locate the position of the staff 



Fig. 487. 




Deep incision in lateral lithotomy. (Fergusson.) 

as regards the prostate. An incision is then made a little 
to the left of the raphe of the perineum, a quarter to half 
an inch in front of the anus, and is carried downward by 



564 SUPRAPUBIC LITHOTOMY. 

careful strokes of the knife until the staff is reached, 
about half an inch in front of the prostate. When the 
point of the knife enters the groove in the staff it is 
pushed backward, keeping it well in the groove until the 
prostate is incised and a gush of fluid escapes along the 
knife, when it is removed and the index finger is then 
introduced and the stone located; lithotomy forceps are 
next introduced and the stone is removed (Fig. 487). 

Suprapubic Lithotomy. The operation of opening the 
bladder above the pubes may be performed for the removal 
of stone from the bladder, or for the extirpation of growths, 
or for drainage of the bladder. The hair on the pubes 
should be shaved off, and the bladder should be injected 
with a few ounces of fluid and a rubber band tied around 
the penis; a small rubber bag is then introduced into the 
rectum empty and filled with air or water. An incision 
two or three inches in length is made in the median line 
of the abdomen just above the symphysis pubis, and is 
deepened gradually until the deep fascia is reached; this 
is divided and exposes the prevesical fat; when this is dis- 
placed the wall of the bladder is exposed to view. A 
tenaculum is next introduced into the highest part of the 
vesical wall, to fix it, and a knife is then thrust through 
the wall of the bladder and the incision is carried down- 
ward about an inch. After the bladder is opened forceps 
are introduced and the calculus is removed. If opened 
for calculus and the bladder-walls are healthy the wound 
may be sutured with stitches which do not pass through 
the mucous coat. The external wound is then sutured 
and the bladder is drained by a soft catheter passed by 
the urethra. If the bladder-walls are much diseased the 
wound is left open, and drainage is effected by a rubber 
tube passed through the suprapubic wound into the bladder. 

CIRCUMCISION. 

Circumcision is performed by drawing the prepuce for- 
ward and then enclosing it in a pair of clamp-forceps 
placed obliquely just in front of the glans (Fig. 488). 



REMOVAL OF THE TESTICLE. 



565 



The prepuce is next divided with a straight bistoury, the 
forceps are removed, and the skin and mucous membrane 
retract. The mucous membrane, if adherent, is dissected 
loose from the glans, and, if redundant, is trimmed off 



Fig. 488. 




Circumcision. 



with scissors, to make it correspond to the line of skin in- 
cision, and the cut edge of the mucous membrane is next 
fastened to the cut edge of the skin by a few sutures of 
silk or catgut. 



REMOVAL OF THE TESTICLE. 

In removing the testicle, a longitudinal incision is made 
over the upper part of the gland and spermatic cord and 
the envelopes of the testicle and cord are divided; the cord 
is then exposed and ligatured, or the different elements 
of the cord may be separated and tied independently; 
it is divided in advance of the ligatures and the gland 
removed. 



566 CESOPHAGOTOMY. 



OPERATION FOR VARICOCELE. 

In operating for varicocele, the dilated veins of the 
spermatic cord may be ligatured by a subcutaneous liga- 
ture passed around the cord, care being taken to see that 
the vas deferens is not included. Or the veins of the cord 
are exposed by an incision an inch and a half or two inches 
in length, at the upper part of the scrotum, over the cord. 
The veins are exposed and the larger portion of them are 
isolated, and two ligatures are passed around the mass of 
veins about an inch or an inch and a half apart and firmly 
tied. The portion of the cord between the ligatures is 
excised and the divided ends of the veins are brought in 
contact by tying together the ends of the ligatures upon 
the proximal and distal ends of the veins; the wound is 
then closed with sutures. 



CHOLECYSTOTOMY. 

An incision three or four inches in length is made verti- 
cally downward from the lower border of the liver opposite 
the tip of the lower border of the tenth rib ; the tissues are 
divided and the peritoneum is opened. The gall-bladder 
is then exposed, opened, and sutured to the edges of the 
wound. If the gall-duct is to be explored, this is done 
with the finger from without or by a probe. After the 
gall-bladder has been opened and the stone removed, it 
may be closed by sutures, or it may be left open, its edges 
being sutured to the external wound. 



EXTERNAL (ESOPHAGOTOMY. 

A sound is passed through the mouth into the oesoph- 
agus until its point comes in contact with the stricture of 
the oesophagus or the foreign body which requires removal. 
An incision is then made from a point one inch above the 
sternum to the line of the upper border of the thyroid 



GASTROSTOMY. 567 

cartilage on the inner side of the sterno-cleido mastoid 
muscle; the anterior jugular vein is displaced, the fascia is 
divided, the omohyoid muscle is drawn aside, the sterno- 
mastoid muscle and the vessels are drawn to the outer side 
with blunt hooks, then by dissecting down with the finger 
the oesophagus is exposed; the sound which has been passed 
into the oesophagus can easily be felt, and the oesophagus 
is incised upon the point of this sound. If a permanent 
opening is desired the edges of the oesophagus are sutured 
to the skin. 

GASTROSTOMY. 

An incision one and a half to two inches in length is made 
parallel to and a finger' s breadth from the border of the left 
costal cartilage, ending opposite the border of the tenth rib ; 
the tissues are divided layer by layer until the peritoneum 
is reached (Fig. 489). The latter membrane should be 
pinched up and opened; the stomach is recognized and 

Fig 489. 




Anatomical relations of stomach. (Stimson.) 

brought out of the wound; the parietal peritoneum is 
stitched to the skin around the wound, and a fold of the 
unopened stomach is brought out of the wound and 
sutured to the parietal peritoneum and the abdominal 
wall. The opening of the stomach is delayed for twenty- 
four hours, if possible, to allow of the formation of adhe- 
sions between its surface and the parietal peritoneum. 



568 GASTROSTOMY. 

Ssabanajew-Frank Method. A curved incision, three or 
four inches in length, is made at the margin of the costal 
cartilages of the left side, and the surface of the stomach 
is exposed. A cone of the stomach wall is then grasped 
by forceps, pulled out of the wound (Fig. 490), and passed 

Fig. 490. 



'" 





Ssabanajew-Frank method ; first stage. (Richardson.) 

under a bridge of skin and connective tissue, and made to 
project from a separate wound made about one and a half 
inches above the original wound (Fig. 491). The wall of 
the stomach is fastened in the original wound by sutures 
and the wound closed, and the projecting portion of the 
stomach in the upper wound is secured by sutures, and 
the stomach can be opened at any time. 

Witzel's Method. This method of gastrostomy also pre- 
vents leakage, and is accomplished by making an incision 
and exposing the wall of the stomach. A small incision is 



GASTROSTOMY. 

Fig. 491. 








569 



Ssabanajew-Frank method ; second stage. (Richardson.) 
Fig. 492. 




Witzel's method ; infolding the tubes. (Richardson.) 



570 



PYLOROPLASTY. 



made in the wall of the stomach, and a rubber tube or 
catheter is introduced; the portion of the tube in contact 
with the stomach external to the wound is then infolded 
by peritoneal approximation, as shown in Fig. 492. The 
stomach is then stitched to the abdominal wall and the 



Fig. 493. 




Witzel's method ; tube infolded and sutures introduced to close the wound. 
(Richardson.) 

external wound closed (Fig. 493). The tube should not be 
removed for a week, but feeding may be begun through 
the tube immediately. Contraction of the fistula may be 
prevented by the occasional introduction of the tube or 
catheter. 

PYLOROPLASTY. 



This operation is practised in the case of non-malignant 
strictures of the pylorus. The pyloric extremity of the 
stomach is exposed by a median incision, and a longitu- 



PYLORECTOMY AND GASTRO-DUODENOSTOMY. 571 

dinal incision is then made through the anterior surface of 
the constricted pylorus (Fig. 494), and the incisiou closed 
by sutures introduced transversely, as shown in Fig. 495. 

Fig. 494. 




Incision in pyloroplasty. (Richardson.) 
Fig. 495. 




Incision closed transversely by sutures. (Richardson.) 



PYLORECTOMY AND GASTRO-DUODENOSTOMY. 

This operation is practised in malignant strictures of the 
pylorus. It consists in exposing the stomach and duo- 
denum by a median incision; the upper portion of the 



572 PYLORECTOMY AND GASTRO-DTJODENOSTOMY. 

duodenum and the stomach are next drawn out through 
the incision, and resection of the diseased portion is accom- 

FlG. 496. 




Lines of incision for excision of pylorus. (Richardson.) 
Fig. 497. 




Pylorus excised and opening into the stomach partially closed. (Richardson.) 



GASTB O-ENTEB OSTOMY. 



573 



plished (Fig. 496). The opening in the stomach being 
much larger than that resulting from resection of the duo- 
denum, the wound in the stomach should be partially 
closed by Lembert sutures (Fig. 497); and when it has 
been reduced to a proper size to fit the free end of the 
duodenum, they are fitted together and held in position 



Fig. 498. 




Gastro-duodenostomy completed. (Richardson.) 

by the introduction of a circular row of closely applied 
Lembert sutures (Fig. 498). 

GASTROENTEROSTOMY. 

This operation may be combined with pylorectorny, or 
in cases where it is inadvisable to resect the pylorus, a 
lateral anastomosis between the stomach and a coil of 
small intestine near the stomach may be made, so that the 
contents of the stomach find their way into the intestine 
through this artificial opening. Where resection of the 
pylorus is combined with gastroenterostomy the method 



574 



OSTEOTOMY. 



of closing the duodenum and stomach and of anastomosis 
between the intestine and the stomach are shown in Fig. 
499. 



Fig. 499. 




Pylorectorny and gastroenterostomy. (Richardson.) 

OSTEOTOMY. 

This operation consists in dividing the bones with a saw 
or osteotome, and is employed to correct deformities of the 
bones. 

Fig. 500. 




Adams' saw. 



The instruments employed are a saw with short cutting 
surface, Adams' saw (Fig. 500), or osteotomes (Fig. 501); 
a heavy mallet is used to drive the osteotome through the 



OSTEOTOMY. 575 

bone. Osteotomy is often employed to correct deformities 
of the hip following coxalgia, and here the femur is divided 
either at the neck, Adams' operation, or just below the 
trochanters, Grant's operation. 

Fig. 501. 




Macewen's osteotome. 

Osteotomy of the Femur below the Trochanters. A 

puncture is made with a bistoury on the outer side of the 
femur just below the great trochanter, and is carried down 
to the bone; the blade of the saw is then introduced and 
the femur is divided by the saw from before backward. 
The femur may also be divided in this position with an 
osteotome. 

Osteotomy for Knock-knee. The operation employed 
to correct this deformity is a transverse section of the 
femur above the condyles (Fig. 502). In the operation 
of supra-condyloid osteotomy the knee is flexed and sup- 
ported on a sand-bag. A longitudinal incision one inch 
in length is made half an inch anterior to the tendon of 
the adductor magnus and a finger's breadth above the 
internal condyle; the knife is carried down to the bone, 
and before it is withdrawn an osteotome is introduced 
and its edge turned so as to divide the bone transversely. 
The section of the bone is accomplished by the use of the 
osteotome and mallet. After the bone has been divided 
the deformity is corrected, the wound is closed, and the 
limb is put up in a pi aster-of -Paris dressing in the cor- 
rected position. 

Osteotomy for Bowlegs. To correct this deformity, 
the tibia and fibula are divided at the point of greatest 
bowing with an osteotome. The fibula is divided first 
at the point of greatest bowing by an osteotome entered 



576 



OSTEOTOMY. 



through a puncture over the fibula, and next the tibia is 
divided in the same manner. The bones being divided, 
the deformity is corrected and the limb is put up in a 



Fig. 502. 




A. Epiphyseal line. C. Line of bone section in supra-condyloid osteotomy. 

plaster-of-Paris dressing in the corrected position. Oste- 
otomy may also be employed to correct deformities in 
other bones, or for the deformity resulting from frac- 
tures united in faulty position. 



NDEX 



ABBE'S lateral anastomosis, 271 
Abdomen, many-tailed band- 
age of, 31 

Abdominal aorta, ligation of, 436 
nephrectomy, 559 

Abscess or abscesses, acute, 298 
chronic, 299 

Hilton's method of opening, 298 
treatment of, 298 
tuberculous, 299 

Absorbent cotton, 159 

Accidents during chloroform anaes- 
thesia, 240 
etherization, 235 

A.-C.-E. mixture, 241 

Acetanilide, 130 

Acetate of aluminum, 130 

Acid, boric, 131 
carbolic, 127 
salicylic, 131 

Acromial end of clavicle, disloca- 
tions of, 392 

Actinomycosis, 120 

Actinomyses, 119 

Actol, 129 

Actual cautery, 180 

Acupuncture, 180 
needles, 180 

Acute abscess, 298 

Adductor longus, tenotomy of, 540 

Administration of chloroform, 239 
of ether, 233 

Aerobic bacteria, 110 

Agnew's splint in fracture of pa- 
tella, 370 

Aluminum acetate, 130 

Ambulatory treatment in fracture 
of leg, 375 
> of thigh, 369 

American bandage of foot, 79 5 



Amputating knives, 455 

saws, 456 
Amputation or amputations, 450 
at ankle-joint, 488 

Hancock's, 491 

Pirogoff's, 489 

Eoux's, 490 

Syme's, 488 

Tripier's, 492 
of arm, 472 
artery forceps in, 457 
bone forceps in, 457 
carpo-metacarpal, 468 
circular, 451 
details of, 459 
at elbow, 470 
elliptical, 453 
of fingers, 463 
flap, 451 
of foot, 480 

Chopart's, 486 

Hey's, 486 

Lisfranc's, 485 
of forearm, 469 
haemostatic forceps in, 458 
of hand, 463 
at hip-joint, 501 
instruments for, 455 
at knee-joint, Carden's, 496 

Gritti's, 498 
of knee-joint, 496 
of leg, 492 

Sedillot's, 495 
ligatures in, 458 
of metacarpal bones, 465 
of metatarsal bones, 483 
Mikulicz's, 492 
modified circular, 454 
oval, 453 
periosteal flaps in, 455 



37 



578 



INDEX. 



Amputation or amputations, peri- 

osteotome in, 457 
rectangular flaps in, 454 
redressing of, 461 
retractors in, 458 
above shoulder-joint, 479 
at shoulder-joint, 474 

Dupuytren's, 477 

Larrey's, 476 

Lisfranc's, 478 

Spence's, 478 

Wyeth's pins in, 475 
subastragaloid, 487 
sutures in, 458 
tarso-metatarsal, 484 
Teale's, 454 
of thigh, 498 
of toes, 480 
tourniquets in, 459 
at wrist, 468 
Anaerobic bacteria, 110 
Anaesthesia from A.-C.-E. mixture, 

241 
after effects of, 243 
from chloroform, 237 
from ether, 231 

from ether and chloroform, 241 
infiltration, 229 
insanity after, 243 
local, 225 

from chloride of ethyl, 226 

from cocaine, 226 

from cold, 225 

from ether, 226 

from eucaine hydrochlorate, 
228 

from guiacol, 228 

from rapid respiration, 226 

from rhigolene, 226 
from oxygen with ether or 

chloroform, 242 
Anaesthetic or anaesthetics, 225 
choice of, 230 

in examination of fracture, 321 
mixture, Schleich's, 241 
Anastomosis forceps, Laplace's, 273 
intestinal, Senn's, 271 
lateral, Abbe's, 271 
Ankle, dislocations of, 412 
-joint, amputations at, 488 

Hancock's, 491 



Ankle-joint, amputations at, Piro- 
goff's, 489 
Koux's, 490 
Syme's, 488 
Tripier's, 492 
strapping of, 168 
Anterior crural nerve, exposure of 
538 
tibial artery, ligation of, 445 
tendon, tenotomy of, 540 
Antipyrin in arterial hemorrhage, 

286 
Antisepsis, 122 

theory of, 120 
Antiseptic bandages, 140 
dressings, moist, 153 
operation, 150 
poultice, 171 

treatment of infected wounds, 156 
Antitoxin, 114 

injection of, 209 
Antrum of Highmore, trephining 

of, 532 
Aorta, abdominal, ligation of, 436 
Appendix vermiformis, removal of, 
561 
McBurney's method, 562 
Approximation sutures, 257 
Aqua ammonia, counter-irritation 
from, 178 
vesication by, 179 
Aristol, 132 

Arm, amputations of, 472 
-and-chest bandages, 66 
spiral reversed bandage of, 57 
Arterial transfusion, 192 
Artery or arteries, ligation of, 418 
(See Special Arteries.) 
forceps, 457 
suture of, 290 
wounded, ligation of, 291 
Arthrectomy of knee-joint, 522 
Arthrogenous spores, 109 
Artificial respiration, 194 
direct, 196 

Laborde's method, 199 
Marshall Hall's method, 199 
Silvester's method, 198 
Ascending spica bandage of groin, 

73 
Asepsis, 122 



INDEX. 



579 



Asepsis, agents to secure, 125 

theory of, 120 
Aseptic bandages, 140 

method, 124 

operation, 149 

preparation for, 145 

treatment of infected wounds, 
156 
Aspiration, 201 

of tuberculous abscess, 299 
Aspirator, Potain's, 201 
Astragalus, excision of, 524 
Auto-transfusion, 192 
Axillary artery, ligature of, 429 



BACILLI, 109 
Bacillus, aerogenes capsulatus, 
119 

anthracis, 118 

coli communis, 116 

of malignant oedema, 118 

mallei, 117 

of tetanus, 118 

tuberculosis, 116 
Bacteria, 108 

aerobic, 110 

anaerobic, 110 

cultivation of, 111 

elimination of, 112 

facultative anaerobic, 110 

infection from, 112 

inoculation by, 111 

intoxication from, 112 

parasitic, 110 

pathogenic action of, 113 

resistance of tissues to, 113 

saphrophytic, 110 

staining of, 111 

of suppuration, 115 

varieties of, 115 
Bacteriology, surgical, 108 
Bandage or bandages, anterior 
figure-of-eight, of chest, 69 

antiseptic, 140 

arm-and chest, Q6 

aseptic, 140 

Barton's, 41 
modified, 42 

circular, 23 

compound, 27 



Bandage or bandages, crossed, of 

eye, 50, 51 
demi- gauntlet, 55 
Desault's, 63 
dimensions of, 20 
elastic webbing, 90 
Estnarch's : 284 
figure-of-eight, 26 

of elbow, 58 

of knee, 77 

of knees, 78 

of leg, 82 

of neck and axilla, 61 
flannel, 88 
of foot, American, 79 

French, 80 

spica, 78 
in fractures, 326 
gauntlet, 54 
gauze, 87 
Gibson's, 44 
handkerchief, 32 
of the head, 41 
for lithotomy position, 84 
many-tailed, 30 
oblique, 23 

of head, 52 

of jaw, 45 
occipito-facial, 52 

-frontal, 53 
paraffin, 105 
plaster-of-Paris, 92 

removal of, 101 

trapping of, 100 
posterior figure-of-eight, of chest, 

70 
recurrent, 26 

of head, 46 

of stump, 83 
removal of, 22 
rubber, 89 
of Scultetus, 86 
silicate of potassium, 104 

of sodium, 104 
spica, 25 

of buttock, 76 

of foot, 78 

of groin, ascending, 73 
descending, 74 

of groins, double, 75 

of shoulder, ascending, 59 



580 



INDEX. 



Bandage or bandages, spica, of 
shoulder, descending, 60 
of thumb, 56 
spiral, 23 
of chest, 69 
of finger, 54 
reversed, 24 

of lower extremity, 81 
of penis, 83 
of upper extremity, 57 
starched, 104 
suspensory, of breast, 71 

of breasts, 73 
transverse recurrent, of head, 48 
of trunk, 69 
V-, of head, 47 
varieties of, 23 
Velpeau's, 62 
Bandaging, 17 
rules for, 21 
Bavarian dressing, 99 
Bed-sores, treatment of, 313 
Beta-naphtol, 129 
Bichloride cotton, 141 
gauze, 139 
of mercury, 126 
Binder's board splints, 106, 324 

in compound fractures, 383 
Bis-axillary cravat, 36 
Bladder, hemorrhage from, 297 
irrigation of, 254 
securing catheter in, 253 
sterilization of, 146 
Blood, transfusion of, 189 
direct, 190 
indirect, 191 
Boiled catgut, 135 
Bond's splint, 357 
Bone chips, decalcified, 213 
forceps, 457 
-grafting, 212 
plates, decalcified, 213 
Bones of forearm, fracture of, 354 

of leg, fractures of, 372 
Boric acid, 131 
Borsch's eye bandage, 85 
Bougies, 247, 250 

sterilization of, 247 
Bovine virus, 207 
Bowlegs, osteotomy for, 575 
Brachial artery, ligation of, 432 



Brachial plexus, exposure of, 537 
Bran bags, 326 
Breast, removal of, 544 

suspensory bandage of, 71, 73 

triangular cap of, 38 
Bromide of ethyl, 242 
Bruises, treatment of, 308 
Brush-burns, treatment of, 309 
Buried sutures, 261 
Burns, powder, treatment of, 308 

treatment of, 309 
Buttock, spica bandage of, 76 
Button suture, 264 



CANTHARIDAL collodion, 179 
Capillary hemorrhage, treat- 
ment of, 293 
Capsicum, counter-irritation from, 

178 
Carbolic acid, 127 
Carbolized gauze, 140 
Carbuncle, strapping of, 168 
Carden's amputation at the knee- 
joint, 496 
Carotid arterv, common, ligation 
of, 424 _ 
external, ligation of, 426 
internal, ligation of, 427 
Carpal bones, dislocation of, 402 

fracture of, 359 
Carpo-metacarpal amputation, 468 
Carpus, dislocation of, 402 
Catgut, boiled, 135 

chromicized, 135 

cumol, 135 

drainage, 137 

dry sterilized, 135 

formalin, 135 

ligatures, 134 

sterilization of, 134, 136 

sutures, 134 

Von Bergmann's, 134 
Catheter or catheters, 247 

female, introduction of, 253 

flexible, 249 

introduction of, 251 

metallic, 249 

securing of, in bladder, 253 

sterilization of, 247 
Catheterization of ureters, 253 



INDEX. 



581 



Cauterization in arterial hemor- 
rhage, 287 
Cautery, actual, 180 

irons, 181 

Paquelin's, 182 

in venous hemorrhage, 292 
Chemical sterilization in wound 

dressing, 143 
Chest, figure-of-eight, bandage of, 
anterior, 69 
posterior, 70 

spiral bandage of, 69 

strapping of, 164 
Chloride of ethyl, local anaesthesia 
from, 226 

of zinc, 130 
Chloroform, 237 

administration of, 239 

anaesthesia, accidents during, 
240 

as a counter-irritant, 177 

vesication by, 179 
Cholecystotomy, 566 
Chopart's amputation of foot, 486 
Chromicized catgut, 135 
Chronic abscess, 299 
Circular amputation, 451 

bandage, 23 
Circumcision, operation of, 564 
Clavicle, dislocation of, 391 
of acromial end of, 392 
sternal end of, 391 

excision of, 516 

fracture of, 338 
in children, 342 
Closed fracture, 317 
Clothing for operation, 149 
Coaptation sutures, 257 
Cocaine, 226 
Coccyx, dislocations of, 389 

excision of, 525 

fracture of, 335 
Cold in arterial hemorrhage, 286 

local, anaesthesia from, 225 

-water dressings, 174 
Colles' fracture, 356 
Colostomy, inguinal, 560 

lumbar, 559 

Maydl's, 561 
Comminuted fracture, 317 
Complete dislocations, 386 



Complete fracture, 316 
Complicated dislocations, 386, 416 

fracture, 318 
Compound bandages, 27 

dislocation, 386, 416 

dorso bis-axillary cravat, 37 

fracture, 317 

fractures, dressing of, 380 
Compresses, 160 

in arterial hemorrhage, 280 

in fractures, 326 
Compression in venous hemor- 
rhage, 293 
Congenital dislocations, 417 
Continued sutures, 262 
Contused wounds, treatment of, 

306 ^ 
Contusions, treatment of, 308 
Coronoid process of ulna, fracture 

of, 353 
Corrosive sublimate gauze, 139 
Costal cartilages, fracture of, 334 
Cotton, 158 

absorbent, 159 

bichloride, 141 

gloves for operations, 148 

sterilized, 141 
Counter-irritation, 175 

from aqua ammonia, 178 

from capsicum, 178 

from chloroform, 177 

from hot water, 176 

from mustard, 177 

from Paquelin's cautery, 178 

Seguin's method, 183 

from spirits of turpentine, 176 
Cravat, bis-axillary, 36 

compound dorso-bis-axillary, 37 

dorso-axillary, 37 

gluteo-inguinal, 39 

mento-vertico-occipital, 35 
Crossed bandage of eye, 50 

of eyes, 51 
Cultivation of bacteria, 111 
Cumol catgut, 135 
Cupping, 184 

dry, 184 

-glass, 185 

wet, 185 
Cystoscope, 215 
Czerny suture, 267 



582 



INDEX. 



DECALCIFIED bone chips, 213 
Deep sutures in arterial hem- 
orrhage, 289 
Demi-gauntlet bandage, 55 
Desault's bandage, 63 
Descending spica bandage of groin, 

74 
Diffused suppuration, 301 
Digital compression in arterial 

hemorrhage, 279 
Diplococci, 110 

Direct method of artificial respira- 
tion, 196 
Dislocation or dislocations, 386 

of ankle, 412 

of carpal bones, 402 

of carpus, 402 

of clavicle, 391 

of coccyx, 389 

complete, 386 

complicated, 386, 416 

compound, 386, 416 

congenital, 417 

of elbow, 398 

of femur, 404 
downward, 406 
posterior, 404 
upward, 408 

of fibula, 411 

of fingers, 402 

of head of radius, 400 

of hip, 404 

of humerus, 393 

Kocher's method in, 396 

of hyoid bone, 390 

of knee, 410 

of lower jaw, 389 

of metacarpal bones, 402, 414 

old, 387, 414 

partial, 386 

of patella, 410 

pathological, 417 

of pelvis, 391 

recent, 387 

of ribs, 390 

of scapula, 393 

of semilunar cartilages, 411 

of shoulder, 393 

simple, 386 

spontaneous, 417 

of sternum, 391 



Dislocation or dislocations of tarsal 
bones, 413 

of thumb, 403 

of toes, 414 

treatment of, 387 

of ulna, 401 

of vertebrae, 388 

of wrist, 401 
Dorsal dislocation of hip, 404 
Dorsalis pedis artery, ligation of, 

447 
Dorso-axillary cravat, 37 
Double ligature, 275 

T-bandage, 29 
Downward dislocations of head of 

femur, 406 
Drainage-tube, 137 
Dressing or dressings, antiseptic, 
improvised, 140 
moist, 153 

aseptic, improvised, 140 

Bavarian, 99 

cold-water, 174 

fixed, 91 

gauze, 139 

dry sterilized, 141 
moist sterilized, 141 

modified moist, in wounds, 144 

moist, in wounds, 144 

plaster-of- Paris, 91 
interrupted, 95 

of wounds, 304 
Dry cupping, 184 

method in wound dressing, 143 

sterilized gauze dressings, 141 
Dupuytren's amputation at shoul- 
der joint, 477 



ELASTIC constriction in arterial 
hemorrhage, 282 

ligature, 278 

tube or strap of Esmarch, 284 

-webbing bandage, 90 
Elbow, amputations at, 470 

dislocations of, 398 

figure-of-eight bandage of, 58 

-joint, excision of, 511 
Electricity, injuries from, 311 
Electrolysis, 214 
Elimination of bacteria, 112 



INDEX. 



583 



Elliptical amputation, 453 
Emulsion of iodoform, 128 
Endogenous spores, 109 
Enema, glycerin, 206 

nutritious, 206 
Enemata, 206 
Epiphyseal fracture, 320 

separation, 320 
Epistaxis, 294 
Erichsen's ligature, 277 
Esmarch's bandage, 284 

elastic strap, 284 
Estlander's operation, 517 
Ether, 231 

administration of, 233 

after effects of, 237 

and chloroform, anaesthesia from, 
241 

first insensibility from, 235 

inhaler, 233 

local anaesthesia from, 226 

preparation of patient for, 231 
Etherization, accidents during, 235 
Ethyl bromide, 242 

chloride, 226 
Eucaine hydrochlorate, 228 
Excision or excisions, 507 

of ankle-joint, 522 

of astragalus, 524 

of clavicle, 516 

of coccyx, 525 

of elbow-joint, 511 

of hip-joint, 519 

instruments for, 508, 509 

of interphalangeal joints, 515 

of joints, 507 

of knee-joint, 520 

of lower jaw, 526 

of metacarpophalangeal joint, 
515 

of os calcis, 524 

of patella, 522 

of ribs, 517 

of scapula, 518 

of shoulder-joint, 510 

of upper jaw, 525 

of wrist, 513 
Exploring needle, 210 
Extensor longus digitorum, ten- 
otomy of, 541 

proprius pollicis, tenotomy of, 541 



External popliteal nerve, exposure 

of, 538 
Eye-bandage, Borsch's, 85 

crossed bandage of, 50 

Liebreich's, 85 
Eyes, crossed bandage of, 51 



FACIAL artery, ligature of, 428 
nerve, exposure of, 536 
Facultative anaerobic bacteria, 110 
Faradization, 215 
Fascia, strains of, treatment of, 315 
Feet, sterilization of, 145 
Felt splints, 325 
Femoral artery, ligation of, 441 

hernia, truss for, 246 
Femur, dislocation of head of, 404 
fracture of, 361 

ambulatory treatment of, 369 
in children, 367 
incomplete, 368 
of lower end of, 366 
neck of, 361 
shaft of, 364 
osteotomy of, 575 
Fermenting poultice, 170 
Fibula, dislocations of, 411 
fracture of, 377 
resection of, 522 
Figure-of eight bandage, 26 
of elbow, 58 
of knee, 77 
of leg, 82 

of neck and axilla, 61 
Fingers, amputations of, 463 
dislocations of, 402 
spiral bandage of, 54 
Fixed dressings, 91 
Flannel bandage, 88 
Flap amputation, 451 
Flat knot, 259 
Flaxesed poultice, 169 
Flexible catheters, 249 
Flexor longus pollicis, tenotomy 

of, 540 
Fly blister, 178 
Fomentations, hot, 171 
Foot, amputations of, 480 
Chopart's, 486 
Hey's, 486 



584 



INDEX. 



Foot, amputations of, Lisfranc's, 
485 
bandage of, American, 79 
French, 80 
spica, 78 
Forced respiration, 200 
Forceps, haemostatic, 283 
Forearm, amputation of, 469 
fracture of, 354 
incomplete, 355 
Formaldehyde, 129 
Formalin, 129 
-gelatin, 129 
Fracture or fractures, 316 
bandages in, 326 
bed, 323 

of bones of forearm, 354 
of leg, 372 
ambulatory treatment of, 
375 
-box, 325 

of carpal bones, 359 
of clavicle, 338 

in children, 342 
closed, 317 
of coccyx, 335 
Colles], 356 
comminuted, 317 
complete, 316 
complicated, 318 
compound, 317 

binder's board splints in, 383 
dressing of, 380 
plaster-of -Paris dressing in, 
382 
compresses in, 326 
of condyles of humerus, 348 
of coronoid process of ulna, 353 
of costal cartilages, 334 
dressings of, provisional, 322 
epiphyseal, 320 
evaporating lotions in, 327 
examination of, 320 
of femur, 361 

ambulatory treatment of, 369 
in children, 367 
incomplete, 368 
of fibula, 377 
of head of radius, 353 
of humerus, 344 
of hyoid bone, 333 



Fracture or fractures, impacted, 
318 

incomplete, 316 

of bones of forearm, 355 

of larynx, 332 

longitudinal, 319 

of lower end of femur, 366 
of radius, 356 
jaw, 331 

of malar bone, 329 

massage in, 327 

of maxillae, 330 

of metacarpal bones, 359 

of metatarsal bones, 379 

multiple, 318 

of nasal bones, 328 

of neck of femur, 361 
of radius, 353 

oblique, 319 

of olecranon process of ulna, 351 

open, 317 

of patella, 369 

of pelvis, 335 

of phalanges, 360 
of toes, 379 

Pott's, 377 

primary roller in, 326 

reduction in, 323 

of ribs, 333 

of sacrum, 335 

of scapula, 343 

setting of, 323 

of shaft of femur, 364 

simple, 317 

of skull, 337 

of sternum, 334 

of tarsal bones, 378 

of tibia, 372 

of toes, 379 

of trachea, 333 

transverse, 319 

ununited, 384 

of upper epiphysis of humerus, 
345 
jaw, 330 

varieties of, 316 

of vertebra?, 336 

of zygoma, 329 
Franklinization, 215 
French bandage of foot, 80 
Frontal sinus, trephining of, 532 



INDEX. 



585 



GALVANO-CAUTERY, 214 
Gastro-duodenostomy, 571 
G astro -enterostomy, 573 
Gastrostomy, 567 

Ssabanajew- Frank method, 568 

WitzePs method, 568 
Gauntlet bandage, 54 
Gauze bandages, 87 

bichloride, 139 

carbolized, 140 

corrosive sublimate, 139 

dressings, 139 

dry, sterilized, 141 
moist, sterilized, 141 

iodoform, 139 

pads, 133 

pledgets, 133 
General anaesthesia, 230 
Gibson's bandage, 44 
Gigli's wire saw, 530 
Gloves for operations, 148 
Gluteal artery, ligation of, 440 
Gluteo-femoral triangle, 39 

-inguinal cravat, 39 
Glutei, 129 
Glycerin enema, 206 

tampon, 160 
Gonococcus, 116 
Granny knot, 260 
Gritti's amputation at the knee- 
joint, 498 
Groin, spica bandage of, ascend- 
ing, 73 
descending, 74 
double, 75 
Guiacol, 228 

Gunshot wounds, treatment of, 307 
Guthrie's amputation at hip-joint, 

503 
Gutta-percha splints, 325 



HEMOSTATIC forceps, 283 
Halsted's mattress suture, 267 
Hamstring tendon, tenotomy of, 

540 
Hancock's amputation at ankle- 
joint, 491 
Handkerchief bandage, 32 
Hand or hands, amputation of, 
463 



Hand, removal of plaster- of- Paris 
from, 101 
sterilization of, 147 
Hardening bandages, 91 
Hare-lip suture, 262 
Hatter's felt splint, 107 
Head, bandage of, 41 
and neck bandage, 49 
oblique bandage of, 52 
recurrent bandage of, 46 
transverse recurrent bandage of, 

48 
V bandage of, 48 
Heat, sterilization by, 125 
Hemorrhage in amputation at hip- 
joint, Wyeth's method in, 504 
arterial, antipyrin in, 286 
cauterization in, 287 
cold, 286 

compresses in, 280 
digital compression in, 279 
elastic constriction in, 282 
hot water in, 286 
ligation in, 288 
position in, 286 
pressure in, 286 
Spanish windlass in, 281 
styptics in, 286 
torsion in, 288 
suture of arteries in, 290 
tourniquets in, 280 
from the bladder, 297 
capillary, treatment of, 293 
control of, in hip-joint amputa- 
tion, 501 
deep sutures in, 289 
from the rectum, 297 
secondary, treatment of, 293 
treatment of, 278 
constitutional, 278 
local, 279 
from the urethra, 296 
venous, cautery in, 292 
compression in, 293 
lateral ligature in, 292 
suture of veins in, 292 
treatment of, 292 
Hernia, femoral, truss for, 246 
inguinal, truss for, 245 
irreducible, truss for, 247 
umbilical, truss for, 246 



586 



INDEX. 



Hey's amputation of foot, 486 
Hilton's method of opening abscess, 

298 
Hip, dislocation of, 404 
dorsal, 404 
ischiatic, 404 
pubic, 408 
thyroid, 406 
-joint, amputation at, 501 
Guthrie's, 503 
hemorrhage in, 501 
Wyeth's method in, 504 
excision of, 519 
anterior, 520 
Horsehair drainage, 137 
Hot air, application of, 219 
sterilizer, 142 
fermentations, 171 
water in arterial hemorrhage, 
286 
counter-irritation from, 176 
Humerus, condyles of, fractures of, 
348 
fracture of, 344 
resection of, 511 

subclavicular, dislocation of, 394 
subcoracoid, dislocation of, 393 
subglenoid, dislocation of, 393 
subspinous, dislocation of, 394 
upper, epiphysis of, separation 
of, 345 
Hydrogen peroxide, 130 
Hyoid bone, dislocation of, 390 

fracture of, 333 
Hypodermic injections, 208 
syringe, 208 



ILIAC artery or arteries, ligation 
of, 437 et seq. 
common, ligation of, 437 
external, ligation of, 439 
internal, ligation of, 439 
transperitoneal ligation of, 438 
Immunity, 114 
Impacted fracture, 318 
Improvised antiseptic dressings, 
140 
aseptic dressings, 140 
Incised wounds, treatment of, 304 
Incision of tuberculous abscess, 300 



Incomplete fracture, 316 

of bones of forearm, 355 
India-rubber suture, 263 
Infected wounds, antiseptic treat- 
ment of, 156 
aseptic treatment of, 156 
Infection from bacteria, 112 
Inferior dental nerve, exposure of, 
535 

thyroid artery, ligation of, 424 
Infiltration anaesthesia, 229 
Inflation, mouth-to-mouth, 195 
Infusion of saline solution, 194 
Inguinal colostomy, 560 
Injection of antitoxins, 209 

of tuberculous abscess, 299 
Injections, urethral, 256 
Injuries from electricity, 311 
Inoculation with bacteria, 111 
Instruments for amputation, 455 

sterilization of, 146 
Internal mammary artery, ligation 
of, 424 

popliteal nerve, exposure of, 538 
Interosseous artery, ligation of, 436 
Interphalangeal joints, excision of, 

515 
Interrupted plaster-of-Paris dress- 
ing, 95 

suture, 261 
Intestinal anastomosis, lateral, 271 

Senn's,_271 
Intestine, circular suture of, 268 
Intravenous injection of saline 

solution, 192 
Intubation of larynx, 553 
operation of, 555 

tubes, 553 
Iodoform, 128 

collodion, 128 

emulsion, 128 

ethereal solution of, 128 

gauze, 139 
Irreducible hernia, truss for, 247 
Irrigation, 171 

of bladder, 254 

immediate, 172 

mediate, 174 
Ischiatic dislocation of hip, 404 
Isinglass plaster, 162 
Itrol, 129 



INDEX. 



587 



JACKET, leather, 106 
«/ plaster of-Paris, 96 
Jaw, lower, dislocations of, 389 
excision of, 526 
fracture of, 331 
oblique bandage of, 45 
upper, excision of, 525 
fracture of, 330 
Joint or joints, ankle, strapping of, 
168 
excision of, 507 
strapping of, 167 
Junk bags, 326 
Jury mast, 98 



KIDNEY, operations upon, 558 
Knee, dislocations of, 410 
figure-of-eight bandage of, 
t 77, 78 

-joint, amputation of, 496 
Garden's, 496 
Gritti's, 498 
arthrectomy of, 522 
excision of, 520 
Knives, amputating, 455 
Knock-knee, osteotomy for, 575 
Koch's law, 112 

Kocher's method of reducing dislo- 
cations of humerus, 396 
Krause's method of skin-grafting, 

212 
Kreolin, 131 



LABOEDE'S method of artificial 
respiration, 199 

Lacerated wounds, treatment of, 
305 

Laminectomy, 532 

Laplace's forceps, 273 

Larrey's amputation at shoulder- 
joint, 476 

Laryngotomy, 551 

Laryngo -tracheotomy, 552 

Larynx, fracture of, 333 
intubation of, 553 

Lateral anastomosis, Abbe's, 271 
ligature in venous hemorrhage, 

292 
lithotomy, 563 



Lavage, 204 

Leather jacket, 106 
splints, 105, 325 

Leech, mechanical, 187 

Leeching, 186 

Leg, amputation of, 492 
Sedillot's, 495 
bandage of, 81 

figure-of-eight bandage of, 82 
fractures of, 872 

ambulatory treatment in, 375 

Lembert's suture, 266 

Lengthening of tendons, 543 

Liebreich's eye bandage, 85 

Ligation of abdominal aorta, 436 
of anterior tibial artery, 444 
in arterial hemorrhage, 288 
of arteries, 418 
of axillary artery, 429 
of brachial artery, 432 
of common carotid artery, 424 

iliac artery, 437 
of dorsalis pedis artery, 447 
of external carotid artery, 426 

iliac artery, 439 
of facial artery, 428 
of femoral artery, 441 
of gluteal artery, 440 
of inferior thyroid artery, 424 
of innominate artery, 420 
of internal carotid artery, 427 
iliac artery, 439 
mammary artery, 424 
of interosseous artery, 436 
of lingual artery, 427 
of occipital artery, 428 
of popliteal arteries, 444 
of posterior tibial artery, 447 
of pudic artery, 441 
of radial artery, 433 
of sciatic artery, 441 
of subclavian artery, 422 
of superior thyroid artery, 427 
of temporal artery, 429 
of ulnar artery, 435 
of vertebral artery, 423 
of wounded arteries, 291 

Ligature or ligatures, 134, 458 
double, 275 
elastic, 278 
Erichsen's, 277 



588 



INDEX. 



Ligature or ligatures, lateral, in 
venous hemorrhage, 292 

quadruple, 275 

securing of, 259 

silk, 134 

single, 274 

subcutaneous, 276 

in vascular growths, 274 
Lightning stroke, 312 
Lingual artery, ligation of, 427 

nerve, exposure of, 536 
Lint, 158 

Lisfranc's amputation of foot, 
485 
at shoulder-joint, 478 
Lithotomy, 563 

left lateral, 563 

position, bandage for, 84 

suprapubic, 564 
Local anaesthesia, 225 
Longitudinal fracture, 319 
Lower jaw, dislocations of, 389 

fracture of, 331 
Lumbar colostomy, 559 

nephrectomy, 559 



McBURNEY'S operation for re- 
moval of appendix, 562 
Mackintosh, 138 
Malar bone, fracture of, 329 
Malignant oedema, bacillus of, 

118 
Many-tailed bandages, 30 
Marshall Hall's method of artificial 

respiration, 199 
Massage, 217 

in fractures, 327 
Mattress suture, 263 

Halsted's, 267 
Mechanical leech, 187 
Median nerve, exposure of, 537 
Mento-vertico occipital cravat, 35 
Mercury, bichloride, 126 
Metacarpal bone, amputations of, 
465 
dislocations of, 402 
resection of, 515 
Metacarpo-phalangeal joint, exci- 
sion of, 515 
Metachromic granules, 109 



Metallic catheters, 249 
Metatarsal bones, amputations of, 
483 
dislocations of, 414 
fractures of, 359, 379 
resection of, 524 
Mikulicz amputation, 492 
Modified circular amputation, 454 

moist dressing in wounds, 144 
Moist antiseptic dressings, 153 
dressings in wounds, 144 
sterilized gauze dressings, 141 
Moulded plaster-of-Paris splints, 
100 
splints, 105 
Mouth to-mouth inflation, 195 
Multiple fracture, 318 
Murphy button, 268 
Muscle-grafting, 213 
Muscles, strains of, treatment of, 

315 
Musculo-spiral nerve, exposure of, 

538 
Mustard, counter-irritation from, 
177 
papers, 177 
plaster, 177 
Mycetoma, 120 



NASAL bones, fracture of, 328 
Neck and axilla, figure-of- 
eight bandage of, 61 
Needle-holder, 259 
Needles, acupuncture, 180 

surgical, 258 
Nephrectomy, abdominal, 559 

lumbar, 559 
Nephrotomy, 558 
Nerve or nerves, anterior crural, 
exposure of, 538 
external popliteal, exposure of, 

538 
facial, exposure of, 536 
grafting of, 213, 534 
inferior dental, exposure of, 535 
internal popliteal, exposure of, 
_ 538 

lingual, exposure of, 536 
median, exposure of, 537 
musculo-spiral, exposure of, 538 



INDEX. 



589 



Nerve or nerves, operation on, 533 

radial, exposure of, 537 

sciatic, exposure of, 538 

spinal accessory, exposure of, 
537 

stretching, 533 

superior maxillary, exposure of, 
535 

supra-orbital, exposure of, 534 

suture of, 533 

ulnar, exposure of, 537 
Neuroplasty, 534 
Neurorrhaphy, 533, 559 
Neurotomy, 533 
Nitrous oxide gas, 230 
Normal salt solution, 193 
Nutritious enema, 206 



OAKUM, 158 
Oblique bandage, 23 
of head, 52 
fracture, 319 
Occipital artery, ligation of, 428 
Occipito-facial bandage, 52 
-frontal bandage, 53 
triangle, 34 
(Esophageal bougie, 205 
(Esophagotomy, 566 
Oiled muslin, 159 

silk, 159 
Old dislocations, 387, 414 
Olecranon process, fracture of, 351 
Open fracture, 317 
Operation or operations, 418 
antiseptic, 150 
aseptic, 149 

preparation for, 144 
clothing for, 149 
cotton gloves for, 148 
upon the kidney, 558 
on nerves, 533 
preparation of patient for, 145 

of room for, 144 
rubber gloves for, 1 48 
upon tendons, 538 
Os calcis, excision of, 524 

fracture of, 378 
Osteoplastic resection of skull, 530 
Osteotomes, 575 
Osteotomy, 574 



Osteotomy for bowlegs, 575 
for knock-knee, 575 
of neck of femur, 575 

Oval amputation, 453 

Oxygen gas with ether or chloro- 
form, 242 



PANELECTKOSCOPE, 217 
Paper-lint, 158 
splints, 325 

Paquelin's cautery, 182 

counter-irritation from, 178 

Paraffin bandage, 105 
paper, 159 

Parafbrm, sterilization of catheters 
by, 247 

Parasitic bacteria, 110 

Parchment paper, 160 

Partial dislocation, 386 

Passive motion, 218 

Pasteboard splints, 106 

Patella, dislocation of, 410 
excision of, 522 
fracture of, 369 

Agnew's splint in, 370 

Pathogenic action of bacteria, 113 

Pathological dislocations, 417 

Patient, preparation of, for opera- 
tion, 145 

Pelvic supporter for application of 
plaster of Paris bandage, 94 

Pelvis, dislocation of, 391 
fracture of, 335 

Penis, spiral reversed, bandage of, 
83 

Periosteal flaps in amputation, 455 

Periosteotome, 457 

Permanganate of potassium, 132 

Peroneal tendons, tenotomy of, 540 

Peroxide of hydrogen, 130 

Petit' s tourniquet, 280 

Phalanges of fingers, fracture of, 
360 
of toes, fracture of, 379 

Pirogoff's amputation at ankle- 
joint, 489 

Plaster or plasters, 161 
bandage saw, 103 

shears, 103 
isinglass, 162 



590 



INDEX. 



Plaster, mustard, 177 
resin, 162 
rubber, 162 
soap, 163 
swan's-down, 162 
PI aster-of -Paris bandage, 92 
application of, 93 
pelvic supporter for applica- 
tion of, 94 
preparation of, 92 
removal of, 101 
Plaster-of-Paris dressings, 91 
in compound fracture, 382 
interrupted, 95 
uses of, 103 
jacket, 96 

removal of, from hands, 101 
splints, 325 
Plate suture, 264 

Poisoned wounds, treatment of, 307 
Polar granules, 109 
Popliteal artery, ligation of, 444 
Porous felt splints, 107 
Position in arterial hemorrhage, 286 
Posterior dislocation of head of 
femur, 404 
tibial artery, ligation of, 447 
tendon, tenotomy of, 540 
Potain's aspirator, 201 
Potassium permanganate, 132 
Poultices, 169 
antiseptic, 171 
fermenting, 170 
flaxseed, 169 
soap, 170 
starch, 170 
Powder burns, treatment of, 308 
Preparation for aseptic operation, 
144 
of patient for operation, 145 
of room for operation, 144 
Pressure in arterial hemorrhage, 

286 
Primary suture of tendons, 542 
Protective, 137 
Pubic dislocation of hip, 408 
Pudic artery, ligation of, 441 
Punctured wounds, treatment of, 

306 
Pyloroplasty, 570 
Pyrozone, 131 



QUADRUPLE ligature, 275 
Quilled suture, 263 
Quilt suture, 263 



RADIAL artery, ligation of, 433 
nerve, exposure of, 537 
Kadius, dislocation of head of, 
400 
fracture of head of, 353 
neck of, 353 
shaft of, 354 
lower end of, 356 
resection of, 512 
Rapid respiration, local anaesthesia 

from, 226 
Rawhide splints, 105 
Ray fungus, 119 
Recent dislocation, 387 
Rectal bougies, 206 

tube, 205 
Rectum, hemorrhage from, 297 

sterilization of, 146 
Recurrent bandage, 26 
of head, 46 

transverse, 48 
of stump, 83 
Reef knot, 259 
Relaxation suture, 257 
Resection or resections, 507 
of bones of leg, 522 
of fibula, 522 
of humerus, 511 
of metacarpal bones, 515 
of metatarsal bones, 524 
of osteoplastic, of skull, 530 
of radius, 512 
of ribs, 517 
of sternum, 517 
of tibia, 522 
of ulna, 512 
Resin plaster, 162 
Respiration, artificial, 194 
direct, 196 

Laborde's method, 199 
Marshall Hall's method, 199 
Silvester's method, 198 
forced, 200 
Retractors, 160, 458 
Rhigolene, local anaesthesia from, 
226 



INDEX. 



591 



Ribs, dislocation of, 390 

excision of, 517 

fracture of, 333 

resection of, 517 
Roller bandage, 18 
Rontgen rays, employment of, 221 
Room, preparation of, for opera- 
tion, 144 
Roux's amputation at ankle-joint, 

490 
Rubber adhesive plaster, 162 

bandage, 89 

-dam, 138 

gloves for operation, 148 

-tissue, 139, 160 
Rubefacients, 176 



OALICYLIC acid, 131 
O Saline solution, 193 
infusion of, 194 
intravenous injection of, 
192 
Sand bags, 326 
Saprophytic bacteria, 110 
Saws, amputating, 456 
Scalds, treatment of, 309 
Scapula, dislocation of, 393 

excision of, 518 

fracture of, 343 
Scarification, 183 
Schizomycetes, 108 
Schleich's anaesthetic mixture, 241 
Sciatic artery, ligation of, 441 

nerve, exposure of, 538 
Scultetus bandage, 86 
Secondary hemorrhage, treatment 
of, 293 

suture of tendons, 543 

sutures, 257 
Sedillot's amputation of leg, 495 
Seguin's method of counter-irrita- 
tion, 183 
Semilunar cartilages, dislocations 

of, 411 
Senn's decalcified bone plates, 213 
Sepsis, 121 
Shock, 302 

prophylaxis of, 302 

treatment of, 302 
Shotted suture, 265 



Shoulder, dislocations of, 393 
spica bandage of, ascending, 59 

descending, 60 
-joint, amputation above, 479 
amputations at, 474 
excision of, 510 
Silicate of potassium bandage, 104 
of sodium bandage, 104 
splints, 325 
Silk ligatures, 134 

sutures, 134 
Silkworm-gut, 134 
Silver foil, 138 

salts, 129 
Silvester's method of artificial 

respiration, 198 
Simple dislocation, 386 

fracture, 317 
Single ligature with pin, 274 

T-bandage, 27 
Sinuses, treatment of, 301 
Sinus, frontal, trephining of, 532 
Skiagraphy, 221 
Skin-grafting, 211 
Krause's method, 212 
Thiersch's method, 211 
Skull, fracture of, 337 

trephining of, 528 
Slings, 30 
Soap plaster, 163 

poultice, 170 
Sounds, 251 

Spanish windlass in arterial hem- 
orrhage, 281 
Spence's amputation at shoulder- 
joint, 478 
Spica bandage, 25 
of buttock, 76 
of foot, 78 
of groin, ascending, 73 

descending, 74 
of groins, double, 75 
of shoulder, ascending, 59 

descending, 60 
of thumb, 56 
Spinal ascending nerve, exposure 

of, 537 
Spiral bandage, 23 
of chest, 69 
of finger, 54 
reversed bandage, 24 



592 



INDEX. 



Spiral, reversed, bandage of arm, 57 
of lower extremity, 81 
of penis, 83 
Spirits of turpentine, counter-irri- 
tation from, 176 
Splint or splints. 324 

binder's board, 106, 324 

Bond's, 357 

felt, 325 

gutta-percha, 325 

hatter's felt, 107 

leather, 105, 325 

moulded, 105 

plaster-of- Paris, 100 

paper, 325 

pasteboard, 106 

I 'laster-of-Paris, 325 

rawhide, 105 

silicate, 325 

wooden , 324 
Sponges, 132 

Spontaneous dislocations, 417 
Spores, arthrogenous, 109 

endogenous, 109 
Sprain fracture, treatment of, 315 
Sprains, strapping in, 314 

treatment of, 314 
Staffordshire knot, 260 
Staining bacteria, 111 
Staphylococci, 110 
Staphylococcus epidermis albus,l 15 

pyogenes albus, 115 
aureus, 115 
Starch poultice, 170 
Starched bandage, 104 
Sterilization of bladder, 146 

of bougies, 247 

of catheters, 247 

of feet, 145 

of hands, 147 

of instruments, 146 

methods of, 122 

of rectum, 146 

of vagina, 146 
Sterilized catgut, 135 

cotton, 141 

gauze dressings, dry, 141 
moist, 141 
Sterilizer, hot-air, 142 
Sterno-cleido- mastoid, tenotomy of, 

541 



Sternum, dislocations of, 391 

fracture of, 334 

resection of, 517 
Stomach-pump, 204 

-tube, 203 
Strains of fascia, treatment of, 315 

of muscles, treatment of, 315 
Strangury, 179 
Strapping, 163 

the ankle-joint, 168 

of carbuncle, 168 

the chest, 164 

of joints, 167 

in sprains, 314 

the testicle, 163 

of ulcers, 165 
Streptobacilli, 110 
Streptococci, 110 
Streptococcus pyogenes, 116 
Streptothrix maduras, 120 
Stump, recurrent bandage of, 83 
Styptics in arterial hemorrhage, 

286 
Subastragaloid amputation, 487 
Subclavian artery, ligation of, 422 
Subclavicular dislocation of hu- 
merus, 394 
Subcoracoid dislocation of humerus, 

393 
Subcutaneous ligature, 276 
Subcuticular suture, 262 
Subglenoid dislocation of humerus, 

393 
Subspinous dislocation of humerus, 

394 
Sulphocarbolate of zinc, 133 
Superior maxillary nerve, exposure 

of, 535 
Suppuration , bacteria of, 115 

diffused, 301 
Supra-orbital nerve, exposure of, 

534 
Suprapubic lithotomy, 564 
Surgeon's knot, 259 
Surgical bacteriology, 108 

needles, 258 

operating bag, 142 
Suspensory bandage of breast, 71 

of breasts, 73 
Suture or sutures, 256 

of approximation, 257 



INDEX. 



593 



Suture or sutures of arteries in ar- 
terial hemorrhages, 290 

buried, 261 

button, 264 

circular of intestine, 268 

of coaptation, 257 

continued, 262 

Czerny, 267 

deep, in arterial hemorrhage, 289 

a distance, 534, 544 

hare-lip, 262 

India-rubber, 263 

interrupted, 261 

Lembert's, 266 

mattress, 263 

of nerves, 533 

plate, 264 

quilt, 263 

of relaxation, 257 

removal of, 266 

secondary, 257 

securing of, 259 

shotted, 265 

silk, 134 

subcuticular, 262 

of tendons, 542 
a distance, 544 
primary, 542 

twisted, 262 

varieties of, 261 

of veins in venous hemorrhage, 
292 
Swan's-down plaster, 162 
Syme's amputation at ankle-joint, 

488 



rP-BANDAGE, 27 



double, 29 
Tampon, 160 
Tarsal bones, dislocations of, 413 

fractures of, 378 
Tarso-metatarsal amputations, 484 
Teale's amputation, 454 
Temporal artery, ligation of, 429 
Tenaculum, 457 

Tendo-Achillis, tenotomy of, 539 
Tendons, lengthening of, 543 
operations upon. 538 
suture of, 542 

secondary, 543 
Tenotomes, 539 



Tenotomy, 538 

of adductor longus,540 

of anterior tibial tendon, 540 

ofextensorlongusdigitorum, 541 
proprius pollicis, 541 

of flexor longus pollicis, 540 

of hamstring tendons, 540 

of peroneal tendons, 540 

of posterior tibial tendon, 540 

of sterno-cleido-mastoid, 541 

of tendo-Achillis, 539 
Tent, 160 
Testicle, removal of, 565 

strapping of, 163 
Tetanus, bacillus of, 118 
Thermometer, clinical, 220 
Thiersch's method of skin-grafting, 

211 
Thigh, amputations of, 498 
Thumb, dislocation of, 403 

spica bandage of, 56- 
Thyroid artery, superior, ligation 
p of, 427 

dislocation of hip, 406 
Tibia, fracture of, 372 

resection of, 522 
Tibial artery, anterior, ligation of, 
444 
posterior, ligation of, 447 
Toes, amputations of, 480 

dislocations of, 414 

fractures of, 379 
Torsion in arterial hemorrhage, 

288 
Tourniquet or tourniquets, 280 

in arterial hemorrhage, 280 

Petit's, 280 
Toxins, 113 

Trachea, fracture of, 333 
Tracheal dilators, 545 

forceps, 546 
Tracheotomy, 544 

director, 545 

high operation, 548 

low operation, 548 

operation of, 548 

tubes, 547 
Transfusion, arterial, 192 

of blood, 189 



indirect, 191 



38 



594 



INDEX. 



Transperitoneal ligation of iliac 

arteries, 438 
Transverse fracture, 319 

recurrent bandage of head, 48 
Trapping plaster-of- Paris bandage, 

100 
Trephine, 528 

Trephining antrum of Highmore, 
"532 

frontal sinus, 532 

the skull, 528 
Triangular cap of breast, 38 
Tripier's amputation at ankle-joint, 

492 
Trunk, bandages of, 69 
Truss or trusses, 244 

for femoral hernia, 246 

for inguinal hernia, 245 

for irreducible hernia, 247 

for umbilical hernia, 246 
Tubercle bacillus, 116 
Tuberculous abscess, 299 
aspiration of, 299 
incision of, 300 
injection of, 299 
Turpentine, spirits of, counter- 
irritation from, 176 

stupe, 176 
Twisted suture, 262 



ULCERS, strapping of, 165 
Ulna, coronoid process of, 
fracture of, 353 
dislocations of, 401 
fracture of, 354 
olecranon process of, fracture 

of, 351 
resection of, 512 
Ulnar artery, ligation of, 435 

nerve, exposure of, 537 
Umbilical hernia, truss for, 246 
Ununited fractures, 384 
Upper extremity, spiral reversed 

bandage of, 57 
Upward dislocation of head of 

femur, 408 
Ureters, catheterization of, 253 
Urethra, hemorrhage from, 296 
Urethra] injections, 256 
Urethroscope, 217 



yACCINATION, 207 
V Vagina, sterilization of, 146 
Varicocele, operation for, 566 
Vascular growths, ligatures in, 274 
V-bandage of head, 48 
Velpeau's bandage, 62 
Venesection, 187 
Venous hemorrhage, treatment of, 

292 
Vertebrae, dislocations of, 388 

fractures of, 336 
Vertebral artery, ligation of, 423 
Vesicants, 178 
Vesication by aqua ammonia, 179 

by chloroform, 179 
Vinegar, inhalation of, after ether, 

237 

WAXED paper, 159 
Wet cupping, 185 
Wooden splints, 324 
Wood-wool, 159 
Wound or wounds, 304 

antiseptic, redressing of, 154 
aseptic, redressing of, 155 
chemical sterilization of, 143 
contused, treatment of, 306 
dressing of, 304 
dry method of dressing, 143 
gunshot, treatment of, 307 
incised, treatment of, 304 

infected, antiseptic treatment 

of, 156 
aseptic treatment of, 156 
lacerated, treatment of, 305 
poisoned, treatment of, 307 
punctured, treatment of, 306 
Wrist, amputations at, 468 
dislocations of, 401 
excision of, 513 
Wyeth's method in hip-joint am- 
putation, 504 
pins in shoulder amputation, 475 



X 



-RAYS, employment of, 221 



yiNC, chloride, 130 
IJ sulpho-carbolate, 130 
Zooglea mass, 110 
Zygoma, fracture of, 329 



CATALOGUE OF PUBLICATIONS OF 

LEA BROTHERS & COMPANY, 

706, 708 & 710 Sansom St., Philadelphia. 
Ill Fifth Ave. (Cor. 18th St.), New York. 

The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the 
United States, on receipt of the printed prices. 

INDEX. 

ANATOMY. _Gray, p. 11 ; Allen, 3 ; Treves, 30 ; Gerrish. 11; Ellis, 9. 

DICTIONARIES. Dunglison, p. 8 ; Duane, 8 ; National, 4. 

PHYSICS. Draper, p. 8 ; Robertson 24. [Schofield, 25. 

PHYSIOLOGY. Foster, p. 10 ; Dalton, 7 ; Chapman, 5 ; Powers, 2* ; 

CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Fownes, 10 ; Chalres, 5 ; 

PHARMACY. Caspari, p. 5 ; Cushny, 6. [Luff, 19 ; Remsen, 24. 

MATERIA MEDICA. Culbretb, p. 6 ; Maisch, 19; Farquharson, P ; 

DISPENSATORY. National, p. 21. [Bruce, 4 : Scbleif, 25. 

THERAPEUTICS. Hare, p. 13 ; Fothergill, 10 ; Wbitla, 31 ; Year- 
Book, 31 ; Hayem & Hare, 14 ; Bruce, 4. 

PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Lyman, 19. 

DIAGNOSIS. Musser, p. 21; Hare, 12; Simon, 25; Herrick, 15; Hutchi- 
son & Rainey, 16. 

CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. [Hamilton, 12. 

NERVOUS DISEASES. Dercum, p. 7 ; Gray, 11 ; Mitchell, 20 ; 

MENTAL DISEASES. Clouston, p. 6 ; Savage, 24 ; Folsom, 10. 

BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy, 30 ; Senn's 
(Surgical), 25. Park, 22. 

HISTOLOGY. Klein, p. 18 ; Schafer's, 25 ; Dunham, 8. 

PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Pepper (Surgical), 23. 

SURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29; 
Bryant, 5; Druitt, 8 ; Cheyne & Burghard, 5. 

SURGERY— OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. 

SURGERY— ORTHOPEDIC. Young, p. 31 ; Gibney, 10. 

SURGERY— MINOR. Wharton, p. 30. 

FRACTURES and DISLOCATIONS. Hamilton, p. 12; Stimson, 27. 

OPHTHALMOLOGY. Norris & Oliver, p. 21; Nettleship, 21 ; Juler,17; 

OTOLOGY. Politzer, p. 23 ; Burnett, 5 ; Field, 9; Bacon, 4. [Berry, 4. 

LARYNGOLOGY and RHINOLOGY. Browne, p. 4, Coakley, 6. 

DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri- 
can System. 2 ; Coleman, 6; Burchard 5. [Morris, 20. 

URINARY DISEASES. Roberts, p. 24 ; Black, 4 ; Purdy, 23 ; 

VENEREAL DISEASES. Taylor, p. 28 ; Hayden, 14 ; Culver & 
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SEXUAL DISORDERS. Fuller, p. 10 ; Taylor, 29. 

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PEDIATRICS. J. Lewis Smith, p. 26 ; Owen, 22 ; Thomson, 29 ; Will- 

HYGIENE. Egbert, p. 9 ; Richardson, 24. 

MEDICAL JURISPRUDENCE. Taylor, p. 28. 

QUIZ SERIES and MANUALS. Pp. 25 and 27. 
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ABBOTT (A. C). PEINCIPLES OF BACTERIOLOGY: a Practical 
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AMERICAN SYSTEM OF PRACTICAL MEDICINE. A SYS- 
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AMERICAN SYSTEM OF DENTISTRY. In treatises by various 
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BUMSTEAD (F. J.) AND TAYLOR (R. W.). THE PATHOLOGY 
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CASPARI (CHARLES JR.). A TREATISE ON PHARMACY. 

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COAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT- 
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COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol. 
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COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY 

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CORNDL (V.). SYPHILIS : ITS MORBID ANATOMY, DIAGNO- 
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CROOK (JAMES K.) ON MINERAL WATERS OF THE 
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CULBRETH (DAVID M. R). MATERIA MEDIC A AND PHAR- 
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CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. 

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DALTON (JOHN C.). A TREATISE ON HUMAN PHYSIOLOGY. 

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DOCTRINES OF THE CIRCULATION OF THE BLOOD. In 

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DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of 

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DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR 
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DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second 
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DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo 
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DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS- 
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3652 pages, with 1585 engravings and 45 full-page plates in colors 
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London Lancet. sidered as the rival of this. — The 

It may be fairly said to represent American Journal of the Medical 

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DERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON 
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DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. 

Their Classification, History, Symptoms, Pathology and Treatment. 
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DRAPER (JOHNC). MEDICAL PHYSICS. A Text-book for Stu- 
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DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF 
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volume of 965 pages, with 373 engravings. Cloth, $4; leather, $5. 

DUANE (ALEXANDER). THE STUDENT'S DICTIONARY OF 
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the medical student that Ave know of. [ Medical Record. 

— Western Med. and Surg. Reporter, j The best student's dictionary. — 
The book is brought accurately to I Canada Lancet. 

date. It is a model of conciseness, | 

DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF 
GYNECOLOGY. Handsome octavo of 652 pages, with 422 illustra- 
tions in black and colors. Cloth, $5.00, net ; leather, $6.00, net. Just 
ready. 



tice of modern gynecology. — Inter- 
national Medical Magazine. 



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DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE 
DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. 
In one octavo volume of 175 pages. Cloth, $1.50. 
DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- 
ENCE. Containing a full explanation of the various subjects and 
terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- 
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- 
gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. 
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of Medicine in the Jefferson Medical College of Philadelphia. Edited 
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book is wholly satisfactory. — Uni- 
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Covering the entire field of medi- 
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DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- 
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Just ready. 
The best one-volume text or refer- 1 of published in America. — Virginia 
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EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; 
leather, $4.50. 
EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
Students and Practitioners. In one handsome 8vo. volume of 576 pages, 
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EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- 
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ELLIS (GEORGE VTNER). DEMONSTRATIONS IN ANATOMY. 
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From the eighth and revised English edition. In one octavo volume 
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EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
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ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- 
GERY. A new American from the eighth enlarged and revised Lon- 
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984 engravings. Cloth, $9 ; leather, $11. 

ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American 

Text-Books of Dentistry, page 2. 

FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 
Fourth American from fourth English edition, revised by Frank 
Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 

FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
EAR. Fourth edition. In one octavo volume of 391 pages, with 73 
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It is just such a work as is needed 
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To those who desire a concise 
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FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND 
PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 
by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 
pages, with engravings. Cloth, $5.00 ; leather, $6.00. 



The work has well earned its lead- 
ing place in medical literature. — 
Medical Record. 

The leading text-book on general 



medicine in the medical schools. — 
Northwestern Lancet. 

The best of American text-books 
on Practice. — Amer. Medico- Surgical 
Bulletin. 

— A MANUAL OF AUSCULTATION AND PERCUSSION ; of 
the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
In one handsome 12mo. volume of 274 pages, with 12 engravings. 

— A PRACTICAL TREATISE ON THE DIAGNOSIS AND 
TREATMENT OF DISEASES OF THE HEART. Second edition 
enlarged. In one octavo volume of 550 pages. Cloth, $4. 

— A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- 
RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- 
EASES AFFECTING THE RESPIRATORY ORGANS. Second 
and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. 

— MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. 

— ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. 
A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 



10 Lea Beothees & Co., Philadelphia and New Yoke. 



FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. 
Cloth, $1.50. With Clouston on Mental Diseases (new edition, see 
page 6) $5.00, net, for the two works. 

FORMULARY, POCKET, see page 32. 

FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New 

(6th) and revised American from the sixth English edition. In one 
large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; 
leather, $5.50. 
Unquestionably the best book that I course, and all that the physician 

can be placed in the student's hands, will need as well. — Dominion Med. 

and as a work of reference for the Monthly. 

busy physician it can scarcely be i For physician, student, or teacher 

excelled. — The Phi la. Polyclinic. 'this is and long will remain the 
This single volume contains all standard, up-to-date work on physi- 

that will be necessary in a college ology. — Virginia Medical Monthly. 

FOTHERGDLL (J. MELNER). THE PRACTITIONER'S HAND- 
BOOK OF TREATMENT. Third edition. In one handsome octavo 
volume of 664 pages. Cloth, $3.75 ; leather, $4.75. 

To have a description of the clearly stated, cannot fail to prove 
normal physiological processes of an a great convenience to many thought- 
organ and of the methods of treat- ful but busy physicians. The prac- 
ment of its morbid conditions tical value of the volume is greatly 
brought together in a single chapter, increased by the introduction of many 
and the relations between the two prescriptions — New York Med. Jour. 

FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
bodying Watts' Physical and Inorganic Chemistry. In one royal 
12mo. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75 ; leather, $3.25. 

FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. 
In one handsome octavo volume of 677 pages, with 51 engravings and 
2 plates. Cloth, $3.75 ; leather, $4.75. 

FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- 
GANS IN THE MALE. In one very handsome octavo volume of 
238 pages, with 25 engravings and 8 full -page plates. Cloth, $2. 

tive and brings views of sound 
pathology and rational treatment to 
many cases of sexual disturbance 
whose treatment has been too often 
fruitless for good. — Annals of 
Surgery. 

FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and 
Treatment. From second English edition. In one 8vo. volume of 475 
pages. Cloth, $3.50. 

GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. _ A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 



It is an interesting work, and one 
which, in view of the large and 
profitable amount of work done in 
this field of late years, is timely and 
well needed. — Medical Fortnightly. 

The book is valuable and instruc- 



GD3BES (HENEAGE). PRACTICAL PATHOLOGY AND MOR- 
BID HISTOLOGY. In one very handsome octavo volume of 314 
pages, with 60 illustrations, mostly photographic. Cloth, $2.75. 

GD3NEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- 
tioners and Students. In one 8vo. vol. profusely illus. Preparing. 



Lea Beothees & Co., Philadelphia and New Yoek. 11 



GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
By American Authors. Edited by Frederic H. Gerrish, M. D. In one 
imp. octavo volume of 915 pages, with 950 illustrations in black and 
colors. Justready. Clth,$6.50; flexible waterproof, $7; leatb.,$7.50,we£. 

In this, the first representative treatise on Anatomy produced in America, 
no effort or expense has been spared to unite an authoritative text with the 
most successful anatomical pictures which have yet appeared in the world. 

The editor has secured the co-operation of the professors of anatomy in 
leading medical colleges, and with them has prepared a text conspicuous 
for its simplicity, unity and judicious selection of such anatomical facts as 
bear on physiology, surgery and internal medicine in the most compre- 
hensive sense of those terms. The authors have endeavored to make a 
book which shall stand in the place of a living teacher to the student, and 
which shall be of actual service to the practitioner in his clinical work, 
emphasizing the most important subjects, clarifying obscurities, helping 
most in the parts most difficult to learn, and illustrating everything by all 
available methods. 

GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. 

GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 
New and thoroughly revised American edition, much enlarged in text, 
and in engravings in black and colors. In one imperial octavo volume 
of 1239 pages, with 772 large and elaborate engravings on wood. Price 
of edition with illustrations in colors : cloth, $7 ; leather, $8. Price 
of edition with illustrations in black : cloth, $6 ; leather, $7. 



ing, and especially the Surgical 
Anatomy. — Chicago 3Ied. Recorder. 

Holds first place in the esteem of 
both teachers and students. — The 
Brooklyn Medical Journal. 

The foremost of all medical text- 
books. — Medical Fortnightly. 

Gray's Anatomy should be the 
first work which a medical student 
should purchase, nor should he be 
without a copy throughout his pro- 
fessional career. — Pittsburg Medical 
Review. 

GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND 
MENTAL DISEASES. For Students and Practitioners of Medicine. 
New (2d) edition. In one handsome octavo volume of 728 pages, with 
172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75. 



This is the best single volume 
upon Anatomy in the English 
language. — University dfedical Mag- 
azine. 

Gray's Anatomy affords the student 
more satisfaction than any other 
treatise with which we are familiar. 
— Buffalo Med. Journal. 

The most largely used anatomical 
text-book published in the English 
language. — Annals of Surgery. 

Particular stress is laid upon the 
practical side of anatomical teach- 



An up-to-date text-book upon 
nervous and mental diseases com- 
bined. A well-written, terse, ex- 
plicit, and authoritative volume 
treating of both subjects is a step in 
the direction of popular demand. — 
The Chicago Clinical Review. 

"The word treatment," says the 
author, "has been construed in the 
broadest sense to include not only 
medicinal and non-medicinal agents, 
but also those hygienic and dietetic 



measures which are often the physi- 
cian's best reliance." — The Journal 
of the American Medical Association. 
The descriptions of the various 
diseases are accurate and the symp- 
toms and differential diagnosis are 
set before the student in such a way 
as to be readily comprehended. The 
author's long experience renders his 
views on therapeutics of great value. 
— The Journal of Nervous and Men- 
tal Disease. 



12 Lea Bkothebs & Co., Philadelphia and New Yoek. 



GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY 
AND MORBID ANATOMY. New (8th) American from the eighth 
London edition. In one handsome octavo volume of 582 pages, with 
216 engravings and a colored plate. Cloth, $2.50, net. Just ready. 



A work that is the text-book of 
probably four-fifths of all the stu- 
dents of pathology in the United 
States and Great Britain stands in 
no need of commendation. The work 
precisely meets the needs and wishes 
of the general practitioner. — The 
American Practitioner and News. 

Green's Pathology is the text-book 



of the day — as much so almost as 
Gray's Anatomy. It is fully up-to- 
date in the record of fact, and so pro- 
fusely illustrated as to give to each 
detail of text sufficient explanation 
The work is an essential to the prac 
titioner — whether as surgeon orphys 
ician. It is the best of up-to-date 
text-books. — Virginia Med. Monthly 



GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM 
ISTRY. For the Use of Students. Based upon Bowman's Medical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75, 

GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA 
Third edition, thoroughly revised and edited by Samuel W. Gkoss 
M. D. In one octavo vol. of 574 pages, with 170 illus. Cloth, $4.50. 

HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN 

comprising those of the Stomach, Oesophagus, Caecum, Intestines 
and Peritoneum. Second American from the third English edition 
In one octavo volume of 554 pages, with 11 engravings. Cloth, $3.50 

HALL, (WINFIELD S.) TEXT-BOOK OF PHYSIOLOGY. Octavo 
about 500 pages, richly illustrated. In press. 

HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 

HAMILTON (FRANK H.). A PRACTICAL TREATISE ON FRAC- 
TURES AND DISLOCATIONS. Eighth edition, revised and edited 
by Stephen Smith, A. M., M. D. In one handsome octavo volume of 
832 pages, with 507 engravings. Cloth, $5.50 ; leather, $6.50. 



Its numerous editions are convin- 
cing proof of its value and popular- 
ity. It is preeminently the authority 
on fractures and dislocations. Thor- 



oughly in accordance with modern 
practice theoretically, mechanically, 
aseptically. — Boston Medical and 
Surgical Journal. 



UARDAWAY (W. A.). MANUAL OF SKIN DISEASES. New (2d) 
edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
2 plates. Cloth, $2.25, net. Just ready. 



The best of all the small books to 
recommend to students and practi- 
tioners. Probably no one of our 
dermatologists has had a wider every - 

HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE 

USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New 
(4th) edition. In one octavo volume of 623 pages, with 205 engravings 
and 14 full-page colored plates. Cloth, $5.00, net. Just ready. 
It is unique in many respects, and 

the author has introduced radical 

changes which will be welcomed by 

all. Anyone who reads this book 

will become a more acute observer, 

will pay more attention to the simple 

yet indicative signs of disease, and 



day clinical experience. His great 
strength is in diagnosis, descriptions 
of lesions and especially in treat- 
ment. — Indiana Medical Journal. 



he will become a better diagnosti- 
cian. This is a companion to Prac- 
tical Therapeutics, by the same 
author, and it is difficult to conceive 
of any two works of greater practical 
utility. — Medical Review. 



Lea Brothers & Co., Philadelphia and New York. 13 



HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL 

THERAPEUTICS, with Special Reference to the Application of Reme- 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
New (7th) and revised edition. In one octavo volume of 776 pages. 
Cloth, $3.75, net; leather, $4.50, net. 



Its classifications are inimitable, 
and the readiness with which any- 
thing can be found is the most won- 
derful achievement of the art of in- 
dexing. This edition takes in all 
the latest discovered remedies. — 
The St. Louis Clinique. 

The great value of the work lies 
in the fact that precise indications 
for administration are given. A 
complete index of diseases and 
remedies makes it an easy refereuce 
work. It has been arranged so that 



it can be readily used in connection 
with Hare's Practical Diagnosis. 
For the needs of the student and 
general practitioner it has no equal. 
— Medical Sentinel. 

The best planned therapeutic work 
of the century. — American Prac- 
titioner and News. 

It is a book precisely adapted to 
the needs of the busy practitioner, 
who can rely upon finding exactly 
what he needs. — The National Med- 
ical Review. 



HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- 
TIONS AND SEQUELS OF TYPHOID FEVER. Octavo, 276 
pages, 21 engravings and two full-page plates. Just ready. Cloth, 
$2.40, net. 



HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- 
TICAL THERAPEUTICS. In a series of contributions by eminent 
practitioners. In four large octavo volumes comprising about 4500 
pages,with about 550 engravings. Vol. IV., just ready. For sale by sub- 
scription only. Full prospectus free on application to the Publishers. 
Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8. 
Price Vol. IV. to former or new subscribers to complete work, cloth, 
$5 ; leather, $6 ; half Russia, $7. Complete work, cloth, $20 ; leather, 
$24 ; half Russia, $28. 



The great value of Hare's System of Practical Therapeutics has led to a 
widespread demand for a new volume to represent advances in treatment 
made since the publication of the first three. More than fulfilling this 
request the Editor has secured contributions from practically a new corps 
of equally eminent authors, so that entirely fresh and original matter is 
ensured. The plan of the work, which proved so successful, has been fol- 
lowed in this new volume, which will be found to present the latest devel- 
opments and applications of this most practical branch of the medical art. 
The entire System is an unrivalled encyclopaedia on the practical parts of 
medicine, and merits the great success it has won for that reason. 



14 Lea Brothers & Co., Philadelphia and New York. 



HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. 
volume, 669 pages, with 144 engravings. Cloth, $2.75 . 



— A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 

12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

— A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 
Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25; leather, $5. 



HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. 

New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- 
gravings. Cloth, $1.50, net. Just ready. 



It is practical, concise, definite 
and of sufficient fulness to be satis- 
factory. — Chicago Clinical Review. 

This work gives all of the prac- 
tically essential information about 
the three venereal diseases, gon- 
orrhoea, the chancroid and syphilis. 
In diagnosis and treatment it is par- 



ticularly thorough, and may be 
relied upon as a guide in the man- 
agement of this class of diseases. — 
Northwestern Lancet. 

It is well written, up to date, and 
will be found very useful. — Inter- 
national Medical Magazine. 



HAYEM (GEORGES) AND HARE (H. A). PHYSICAL AND 
NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pages,with 113 engravings. Cloth, $3. 



This well-timed up-to-date volume 
is particularly adapted to the re- 
quirements of the general practi- 
tioner. The section on mineral 
waters is most scientific and prac- 
tical. Some 200 pages are given up 
to electricity and evidently embody 
the latest scientific information on 
the subject. Altogether this work 
is the clearest and most practical aid 
to the study of nature's therapeutics 
that has yet come under our obser- 
vation. — The Medical Fortnightly. 

For many diseases the most potent 
remedies Jie outside of the materia 
medica, a fact yearly receiving wider 



j recognition. Within this large 
range of applicability, physical 
agencies when compared with drugs 
are more direct and simple in their 
results. Medical literature has long 
been rich in treatises upon medical 
agents, but an authoritative work 
upon the other great branch of 
therapeutics has until now been a 
desideratum. The section on climate, 
rewritten by Prof. Hare, will, for 
the first time, place the abundant 
resources of our country at the in- 
telligent command of American 
practitioners. — The Kansas City 
Medical Index. 



HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 

one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
Student's Series of Manuals, page 27. 



HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. 
volume of 199 pages, with 32 engravings. Cloth, $1.50. 



Lea Brothers & Co., Philadelphia and New York. 15 



HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 
one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
colored plates. Cloth, $2.50. 



Excellently arranged, practical, 
concise, up-to-date, and eminently 
well fitted for the use of the prac- 
titioner as well as of the student. — 
Chicago 3Ied. Recorder. 

This volume accomplishes its ob- 
jects more thoroughly and com- 
pletely than any similar work yet 
published. Each section devoted to 
diseases of special systems is pre- 
ceded with an exposition of the 
methods of physical, chemical and 



microscopical examination to be em- 
ployed in each class. The technique 
of blood examination,including color 
analysis, is very clearly stated. 
Uranalysis receives adequate space 
and care. — New York Med. Journal. 
We commend the book not only to 
the undergraduate, but also to the 
physician who desires a ready means 
of refreshing his knowledge of diag- 
nosis in the exigencies of professional 
life. — Memphis Medical Monthly. 



TTTTiTi (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 

HELL.IER (THOMAS). A HANDBOOK OF SKIN DISEASES. 
Second edition. In one royal 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON C.) AND PD3RSOL (GEORGE A.). HUMAN 

MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, $5. Limited edition. For sale 
by subscription only. 

HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
In one 12mo. volume of 520 double-columned pages. Cloth, $1.50 ; 
leather, $2. 

HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. 

HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 

HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- 
ciples and Practice. A new American from the fifth English edition. 
Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- 
ume of 1008 pages, with 428 engravings. Cloth, $6 ; leather, $7. 



— A SYSTEM OF SURGERY. With notes and additions by various 
American authors. Edited by John H. Packard, M. D. In three 
very handsome 8vo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather, $7 ; half Russia, $7.50. For sale by subscription only. 



16 Lea Brothebs & Co., Philadelphia and New York. 



HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS- 
TOLOGY. Eighth edition, revised and modified. In two large 8vo. 
volumes of 1007 pages, containing 320 engravings. Cloth, $6. 



HUDSON (A.). LECTURES ON THE STUDY OF FEVER, 
octavo volume of 308 pages. Cloth, $2.50. 



In one 



HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL 
METHODS. A GUIDE TO THE PRACTICAL STUDY OF 
MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- 
ings and 8 colored plates. Cloth, $3.00. 



A comprehensive, clear and re- 
markably up-to-date guide to clinical 
diagnosis. The illustrations are 
plentiful and excellent. As exam- 
ples of the more recent additions to 



medical knowledge which receive 
recognition, we mention Widal's 
test for typhoid and the Neuron 
theory of the nervous system. — 
Montreal Medical Journal. 



HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. 
volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. 
See Series of Clinical Manuals, p. 25. 

HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS- 
EASES OF THE SKIN. New (4th) edition, thoroughly revised. 
In one octavo volume of 815 pages, with 110 engravings and 12 full- 
page plates, 4 of which are colored. Cloth, $5.25 ; leather, $6.25. 



This edition has been carefully re- 
vised, and every real advance has 
been recognized. The work answers 
the needs of the general practitioner, 
the specialist, and the student. — The 
Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by conscientious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in- 
culcated throughout is sound as well 



as practical. — The American Jour- 
nal of the Medical Sciences. 

It is the best one-volume work 
that we know. The student who 
gets this book will find it a useful 
investment, as it will well serve him 
when he goes into practice. — Vir- 
ginia Medical Semi- Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg Medical Review. 

It is the most practical hand- 
book on dermatology with which we 
are acquainted. — The Chicago Med- 
ical Recorder. 



JACKSON (GEORGE THOMAS). THE READY-REFERENCE 
HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. 
In one 12mo. volume of 637 pages, with 75 illustrations and a colored 
plate. Just ready. Cloth, $2.50, net. 



A prompt and ready source of J 
knowledge on all points of termin- 
ology, symptoms, varieties, etiology, 
pathology, diagnosis, treatment and 
prognosis of dermal affections. Ta- ! 
ties of differential diagnosis and \ 
standard prescriptions will be found 
scattered through the text, and the ! 
work ends with an appendix of well- 
tried formulae. The series of illus- 
trations is rich and instructive. — 
Memphis Med. Monthly. 

The text is clear and sufficiently 
full. The subject of treatment in- 



cludes all the newer methods and 
remedies of proved value. It is a 
thoroughly satisfactory and clear 
expression of cutaneous diseases. — 
American Journal of the Medical 
Sciences. 

The work is fair and accurate, full 
and complete, and it embodies the 
recent additions to our information. 
Above all, it is eminently practical. 
The reviewer has found it a good 
book for students, and believes it is 
equally good for the practitioner. — 
Chicago Clinical Review. 



Lea Bkothers & Co., Philadelphia and New York. 17 



JAMEESON (W. ALLAN). DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographic plates. Cloth, $6. 

JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. . In one 
12mo. volume of 356 pages, with 80 engravings and 3 colored plates. 
Cloth, $2.25. Just ready. 



An exceedingly useful manual for 
student and practitioner. The au- 
thor has succeeded unusually well 
in condensing the text and in arrang- 



ing it in attractive and easily tangi- 
ble form. The book is well illus- 
trated throughout. — Nashville Jour, 
of Medicine and Surgery. 



— THE PRACTICE OF OBSTETRICS. By American Authors. 
One large octavo volume of 763 pages, with 441 engravings in black 
and colors, and 22 full-page colored plates. Just ready. Cloth, 
$5.00, net; leather, $6.00, net. 

the book abounds. The work is 
sure to be popular with medical 
students, as well as being of extreme 
value to the practitioner. — The 
Medical Age. 



A clear and practical treatise upon 
obstetrics by well-known teachers of 
the subject. A special feature of 
this work would seem to be the 
excellent illustrations with which 



JONES (C. HANDF1ELD). CLINICAL OBSERVATIONS ON 
FUNCTIONAL NERVOUS DISORDERS. Second American edi- 
tion. In one octavo volume of 340 pages. Cloth, $3.25. 



JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 
AND PRACTICE. Second edition. In one octavo volume of 549 
>ages, with 201 engravings, 17 chromo-lithographic plates, test-types of 
Taeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, 
$5.50 ; leather, $6.50. 



pa 



The volume is particularly rich in 
matter of practical value, such as 
directions for diagnosing, use of 
instruments, testing for glasses, for 
color blindness, etc. The sections 
devoted to treatment are singularly 
full, and at the same time concise, 



and couched in language that can- 
not fail to be understood. This 
edition likewise embodies such re- 
visions and changes as were neces- 
sary to render it thoroughly repre- 
sentative. — Medical Age. 



KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. 
In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, 
$2.50. 



The student world seems thor- 
oughly conversant with the merits 
of this manual, for there is certain- 
ly no work upon obstetrics more in 
demand by them. This edition has 
been thoroughly revised to represent 
recent advances in its subject, special 
attention being devoted to aseptic 
midwifery. The book is increased 
in size, and a number of illustra- 
tions has been added to its already 



rich store. — Memphis Med. Monthly. 
From first to finish it is thoroughly 
practical, concise in expression, well 
illustrated, and includes a statement 
of nearly every fact of importance 
discussed in obstetric treatises or 
cyclopedias. The well-arranged 
index renders the book useful to 
the practitioner who is in haste to 
refresh his memory. — Virginia 
Medical Semi-Monthly. 



KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome 
octavo of 700 pages, with 751 illustrations. Just ready. See American 
Text-Books of Dentistry, page 2. 



18 Lea Brothers & Co., Philadelphia and New York. 



KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In 
one 12mo. volume of 506 pages, with 296 engravings. Just ready. 
Cloth, $2.00, net. See Student's Series of Manuals, page 27. 



It is the most complete and con- 
cise work of the kind that has yet 
emanated from the press, and is 
invaluable to the active as well as 
to the embryo practitioner. The 
illustrations are vastly superior to 
those in most works of its class. — 
The Medical Age. 

The clear and concise manner in 



which it is written, the absence oi 
debatable matter, and of conflicting 
views, the convenient size of the 
book and its moderate price, will 
account for its undoubted success. — 
Medical Chronicle. 

This work deservedly occupies a 
first place as a text-book on his- 
tology. — Canadian Practitioner. 



LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 
handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

LA ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 
pages. Cloth, $7. 



PNEUMONIA. In one 8vo. volume of 490 pages. Cloth, $3. 



LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 



LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 
Complete work just ready. 

CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; 

CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI- 
THE ENDEMONIADAS ; EL SANTO NINO DE LA GUARDIA; 
BRIANDA DE BARDAXI. In one 12mo. volume of 522 pages. 
Cloth, $2.50. 



— FORMULARY OF THE PAPAL PENITENTIARY, 
octavo volume of 221 pages, with frontispiece. Cloth, $2.50. 



In one 



— SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 
OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
TORTURE. Fourth edition, thoroughly revised. In one hand- 
some royal 12mo. volume of 629 pages. Cloth, $2.75. 



— STUDIES IN CHURCH HISTORY. The Rise of the Temporal 
Power — Benefit of Clergy — Excommunication. New edition. In one 
handsome 12mo. volume of 605 pages. Cloth, $2.50. 



— AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 
IN THE CHRISTIAN CHURCH. Second edition. In one hand- 
some octavo volume of 685 pages Cloth, $4.50. 



LEE (HENRY) ON SYPHILIS. In one 8vo. volume of 246 pages. 
Cloth, $2.25. 

LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. 
In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. 



Lea Brothees & Co., Philadelphia and New \oek. 19 

LOOMIS (ALFRED L.) AND THOMPSON (W. GDLMAN, 

EDITORS). A SYSTEM OF PEACTICAL MEDICINE. In 

Contributions by Various American Authors. In four very hand- 
some octavo volumes of about 900 pages each, fully illustrated in 
in black and colors. Complete work now ready. Per volume, cloth, 
$5 ; leather, $6 ; half Morocco, $7. For sale by subscription only. 
Full prospectus free on application to the Publishers. See American 
System of Practical Medicine, page 2. 

LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of 

Students of Medicine. In one 12mo. volume of 522 pages, with 36 
engravings. Cloth, $2. See Student's Series of Manuals, page 27. 



LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 

very handsome octavo volume of 925 pages, with 170 engravings. 
Cloth, $4.75 ; leather, $5.75. 



An excellent treatise on the prac- 
tice of medicine, written by one 
who is not only familiar with his 
subject, but who has also learned 
through practical experience in 
teaching what are the needs of the 
student and how to present the facts 
to his mind in the most readily 
assimilable form. The practical and 
busy physician, who wants to ascer- 
tain in a short time all the necessary 
facts concerning the pathology or 



treatment of any disease will find 
here a safe and convenient guide. — 
The Charlotte Medical Journal. 

Complete, concise, fully abreast or 
the times and needed by all students 
and practitioners. — Univ. Med. Mag. 

An exceedingly valuable text-book. 
Practical, systematic, complete and 
well balanced. — Chicago Med. Re- 
corder. 

Represents fully the most recent 
knowledge. — Montreal Med. Jour. 



LYONS (ROBERT D.). A TREATISE ON FEVER, 
volume of 362 pages. Cloth, $2.25. 



In one octavo 



MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. 

Handsome octavo, about 600 pages, richly illustrated. Preparing. 

MA1SCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
MEDICA. New (7th) edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 
285 engravings. Just ready. Cloth, $2.50, net. 



The best handbook upon phar- 
macognosy of any published in this 
country. — Boston Med. & Sur. Jour. 

Noted on both sides of the Atlantic 
and esteemed as much in Germany as 
in America. The work has no equal. 
— Dominion Med. Monthly. 

Used as text-book in every college 
of pharmacy in the United States 
and recommended in medical col- 
leges. — American Therapist. 



New matter has been added, and 
the whole work has received careful 
revision, so as to conform to the new 
United States Pharmacopoeia. — Vir- 
ginia Medical Monthly. 

This standard text-book is a 
work of such well-tried merit that it 
stands in no danger of being super- 
seded. — Amer. Druggist and Pharm. 
Record. 



20 Lea Brothers & Co., Philadelphia and New York. 



MANUALS. See Student's Quiz Series, page 27, Student's Series of 
Manuals, page 27, and Series of Clinical Manuals, page 25. 

MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 
volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. 
In one 12mo. volume of about 400 pp., fully illustrated. Preparing. 

MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For 
the use of Students and Practitioners. Second edition, revised by L. 
S. Ratj, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
ings. Cloth, $1.75. 

MEDICAL NEWS POCKET FORMULARY, see page 32. 

MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS 

DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
and 2 colored plates. Cloth, $2.50. Of the hundred numbered copies 
with the Author's signed title page a few remain ; these are offered 
in green cloth, gilt top, at $3.50, net. 



There is no question as to the in- 
terest of the clinical pictures pre- 
sented in this volume. Many rare 
examples of spurious troubles 
(hysteria) are given and irregular 
types of other " nervous " affections. 
The study of these types, from the 
author's clear notes and deductions, 
will be of value to the student of 
neurology. — The Chicago Clinical 
Review. 

This is a book by a master and if 
we mistake not it will prove a very 



popular one. The book treats of 
hysteria, recurrent melancholia, dis- 
orders of sleep, choreic movements, 
false sensations of cold, ataxia, 
hemiplegic pain, treatment of sci- 
atica, erythromelalgia, reflex ocular 
neurosis, hysteric contractions, ro- 
tary movements in the feeble 
minded, etc. Few can speak with 
more authority than the author. — 
The Journal of the American Medi- 
cal Association. 



MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN- 
JURIES OF NERVES AND THEIR TREATMENT. In one 

handsome 12mo. volume of 239 pages, with 12 illustrations. Cloth, $1.75. 



Injuries of the nerves are of fre- 
quent occurrence in private practice, 
and often the cause of intractable 
and painful conditions, conse- 
quently this volume is of especial 
interest. Doctor Mitchell has had 
access to hospital records for the last 
thirty years, as well as to the 



government documents, and has 
skilfully utilized his opportunities. 
This work will doubtless take a 
prominent place in medical litera- 
ture among the special monographs 
which throw light into obscure 
places and contribute to the advance 
of medical science. — The Med. Age. 



MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) 
edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- 
graphic plates and 26 engravings. Cloth, $3.25, net. Just 



MUIiliER (J.). PRINCIPLES OF PHYSICS AND METEOROL- 
OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. 



Lea Brothers & Co., Philadelphia and New York. 21 



MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL 

DIAGNOSIS, for Students and Physicians. New (2d) edition, thor- 
oughly revised. In one octavo volume of 931 pages, with 177 engrav- 
ings and 11 full-page colored plates. Cloth, $5 ; leather, $6. 



We have no work of equal value 
in English. — University Medical 
Magazine. 

Every real advance that has been 
made in this rapidly progressing 
department of medicine is here re- 
corded. There is no half knowledge. 
His descriptions of the diagnostic 
manifestations of diseases are accu- 
rate. This work will meet all the 
requirements of student and physi- 
cian. — The Medical News. 

From its pages may be made the 
diagnosis of every malady that 
afflicts the human body, including 
those which in general are dealt 



with only by the specialist. The 
early demand for the new edition 
speaks volumes for the book's popu- 
larity. — Northwestern Lancet. 

It so thoroughly meets the precise 
demands incident to modern research 
that it has been already adopted as a 
leading text-book by the medical 
colleges of this country. — North 
American Practitioner. 

Occupies the foremost place as a 
thorough, systematic treatise. — Ohio 
Medical Journal. 

The best of its kind, invaluable to 
the student, general practitioner and 
teacher. — Montreal Medical Journal. 



NATIONAL DISPENSATORY. See Stille, Maisch & Caspari, p. 27. 

NATIONAL FORMULARY. See Stille, Maisch & Caspari' s National 
Dispensatory, page 27. 

NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 



NETTLESHD? (E.). DISEASES OF THE EYE. New (5th) American 
from sixth English edition, thoroughly revised. In one 12mo. volume 
of 521 pages, with 161 engravings, and 2 colored plates, test-types, 
formula? and color-blindness test. Cloth, $2.25. Just ready. 



By far the best student's text-book 
on the subject of ophthalmology and 
is conveniently and concisely ar- 
ranged. — The Clinical Review. 

It has been conceded by ophthal- 
mologists generally that this work 
for compactness, practicality and 
clearness has no superior in the 



English language. — Journal of 
Medicine and Science. 

The present edition is the result 
of revision both in England and 
America, and therefore contains the 
latest and best ophthalmological 
ideas of both continents. — The Phy- 
sician and Surgeon. 



NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engravings and 5 colored plates. Cloth, $5 ; leather, $6. 



We take pleasure in commending 
the " Text-book " to students and 
practitioners as a safe and admir- 
able guide, well qualified to furnish 
them, as the authors intended it 
should, with "a working knowl- 
edge of ophthalmology." — Johns 
Hopkins Hospital Bulletin. 

The first text-book of diseases of 
the eye written by American authors 
for American colleges and students. 
Every method of ocular precision 
that can be of any clinical advantage 



to the every-day student and the 
scientific observer is offered to the 
reader. Rules and procedures are 
made so plain and so evident, that 
any student can easily understand 
and employ them. It is practical in 
its teachings. We unreservedly en- 
dorse it as the best, the safest and the 
most comprehensive volume upon 
the subject that has ever been offered 
to the American medical public. — 
Annals of Ophthalmology and Oto- 



22 Lea Beothbbs & Co., Philadelphia and New York. 



OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 

In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 



PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- 
CAN AUTHORS. In two handsome octavo volumes. Volume L, 
General Surgery, 799 pages, with 356 engravings and 21 full-page 
plates, in colors and monochrome. Volume II., Special Surgery, 
800 pages, with 430 engravings and 17 full-page plates, in colors 
and monochrome. Per volume, cloth, $4.50; leather, $5.50. Net. 
Complete work now ready. 



The work is fresh, clear and practi- 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
practitioner. The pathology is 
broad, clear and scientific, while the 
suggestions upon treatment are 
clear-cut, thoroughly modern and 
admirably resourceful. — Johns Hop- 
kins Hospital Bulletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus Medical Journal. 

Its special field of application is 
in practical, every-day use. It well 
deserves a place in every medical 
man's library. — The Pittsburg Med- 
ical Review. 

The illustrations are almost en- 



tirely new and executed in such a 
way that they add great force to the 
text. It gives us unusual pleasure 
to recommend this work to students 
and practitioners alike. — The Chi- 
cago Medical Recorder. 

The various writers have em- 
bodied the teachings accepted at 
the present hour aud the methods 
now in vogue, both as regards 
causes and treatment. — The North 
American Practitioner. 

Both for the student and practi- 
tioner it is most valuable. It is 
thoroughly practical and yet thor- 
oughly scientific. — Medical News. 

A truly modern surgery, not only 
in pathology, but also in sound 
surgical therapeutics. — New Or- 
leans Med. and Surgical Journal. 



PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND 
SURGERY. 12mo., about 550 pages, fully illustrated. In press. 

PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 



PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB- 
STETRICS. Third edition. In one handsome octavo volume of 
677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
leather, $5.25. 



In the foremost rank among the 
most practical and scientific medical 
works of the day. — Medical News. 

It ranks second to none in the 
English language. — Annals of Gyne- 
cology and Pediatry. 

The book is complete in every de- 
partment, and contains all the neces- 
sary detail required by the modern 



practising obstetrician. — Interna- 
tional Medical Magazine. 

Parvin's work is practical, con- 
cise and comprehensive. We com- 
mend it as first of its class in the 
English language. — Medical Fort- 
nightly. 

It is an admirable text-book in 
every sense of the word. — Nashville 
Journal of Medicine and Surgery. 



Lea Brothers & Co., Philadelphia and New York. 23 

PEPPER'S SYSTEM OF MEDICINE. See page 3. 

PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's 

Series of Manuals, page 27. 

SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 



with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 

PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 

In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND 
PRACTICE OF MIDWIFERY. Seventh American from the ninth 
English edition. In one octavo volume of 700 pages, with 207 
engravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. Just 
ready. 

In the numerous editions which 
have appeared it has been kept con- 
stantly in the foremost rank. It is 
a work which can be conscientiously 
recommended to the profession. — 
The Albany Medical Annals. 

This work must occupy a fore- 
most place in obstetric medicine as I Medical Fortnightly 
a safe guide to both student and ! 



obstetrician. It holds a place among 
the ablest English-speaking authori- 
ties on the obstetric art. — Buffalo 
Medical and Surgical Journal. 

An epitome of the science and 
practice of midwifery, which em- 
bodies all recent advances. — The 



THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 
TION AND HYSTERIA. In one 12mo. volume of 97 pages. 
Cloth, $1. 

POCKET FORMULARY, see page 32. 

POL.ITZER ( ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
EAR AND ADJACENT ORGANS. Second American from the 
third German edition. Translated by Oscar Dodd, M. D., and 
edited by Sir William Dalby, F. R. C. S. In one octavo volume of 
748 pages, with 330 original engravings. Cloth, $5.50. 

The anatomy and physiology of | ment are clear and reliable. We 
each part of the organ of hearing j can confidently recommend it, for it 
are carefully considered, and then j contains all that is known upon the 
follows an enumeration of the dis- subject. — London Lancet. 
eases to which that special part of | A safe and elaborate guide into 
the auditory apparatus is especially j every part of otology. — American 
liable. The indications for treat- j Journal of the Medical Sciences. 

POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In 
one 12mo. volume of 396 pages, with 47 engravings. Cloth, $1.50. 
See Student's Series of Manuals, page 27. 

PROGRESSIVE MEDICINE, see page 32. 

PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED 
AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
pages, with 18 engravings. Cloth, $2. 



24 Lea Brothebs & Co., Philadelphia and New York. 



PXE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 
12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. 

QUIZ SERIES. See Student' 's Quiz Series, page 27. 

RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 

12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
Student's Series of Manuals, page 27. 

RAMSBOTHAM (FRANCIS H). THE PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND SURGERY. In one 
imperial octavo volume of 640 pages, with 64 plates and numerous 
engravings in the text. Strongly bound in leather, $7. 

REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. 

In one handsome octavo volume of about 800 pages, richly illustrated. 
Preparing. 

REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- 
ISTRY. New (5th) edition, thoroughlv revised. In one 12mo. vol- 
ume of 326 pages. Cloth, $2. 



A clear and concise explanation 
of a difficult subject. We cordially 
recommend it. — The London Lancet. 

The book is equally adapted to the 
student of chemistry or the practi- 
tioner who desires to broaden his 
theoretical knowledge of chemistry. 
— New Orleans Med. and Surg. Jour. 

The appearance of a fifth edition 
of this treatise is in itself a guarantee 



that the work has met with general 
favor. This is further established 
by the fact that it has been trans- 
lated into German and Italian. The 
treatise is especially adapted to the 
laboratory student. It ranks unusu- 
ally high among the works of this 
class. This edition has been brought 
fully up to the times. — American 
Medico-Surgical Bulletin. 



RICHARDSON (BENJAMIN WARD) PREVENTIVE MEDI- 
CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. 

ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. In one octavo volume of 780 pages, with 
501 engravings. Cloth, $4.50 ; leather, $5.50. 



THE COMPEND OF ANATOMY. For use in the Dissecting 

Room and in preparing for Examinations. In one 16mo. volume of 
196 pages. Limp cloth, 75 cents. 

ROBERTS (SIR WDLL.IAM). A PRACTICAL TREATISE ON 
URINARY AND RENAL DISEASES, INCLUDING URINARY 
DEPOSITS. Fourth American from the fourth London edition. In 
one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 

ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. 
In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. 
See Student's Series of Manuals, page 27. 

ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE 
NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, 
with 184 engravings. Cloth, $4.50 ; leather, $5.50. 



SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, 
PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, 
with 18 typical engravings. Cloth, $2. See Series of Clinical Man- 
uals, page 25. 



Lea Brotheks & Co., Philadelphia and New York. 26 

SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- 
OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. 
New (5th) edition. In one handsome octavo volume of 359 pages, 
with 392 illustrations. Cloth, $3.00, net. Just ready. 



Nowhere else will the same very 
moderate outlay secure as thoroughly 
useful and interesting an atlas of 
structural anatomy. — The American 
Journal of the Medical Sciences. 



The most satisfactory elementary 
text-book of histology in the Eng- 
lish language. — The Boston Med. and 
Sur. Jour. 



— A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. 
In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 



The book very nearly approaches 
perfection. Methods are given with 
an accuracy of detail and prevision 
of difficulties which can hardly be 



overpraised. It bears eloquent tes- 
timony to the wide knowledge and 
untiring industry of its author. — 
The Scottish Med. and Surg. Jour. 



SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, 
PRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo., 
352 pages. Cloth, $1.50, net. Just ready. Lea's Series of Pocket 
Text-books. Edited by Bern B. Gallaudet, M. D. 

SCHMITZ AND ZUMPT'S CLASSICAL SERIES. Advanced 
Latin Exercises. Cloth, 60 cts. Schmidt's Elementary Latin Exer- 
cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 
cents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents. 

SCHOFEELD (ALFRED T.). ELEMENTARY PHYSIOLOGY 
FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 
engravings and 2 colored plates. Cloth, $2. 

SCHRED3ER (JOSEPH). A MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EXERCISE. Octavo 
volume of 274 pages, with 117 engravings. 

SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- 
tion. In one octavo volume of 268 pages, with 13 plates, 10 of which 
are colored, and 9 engravings. Cloth, $2. 

SERIES OF CLINICAL MANUALS. A Series of Authoritative 
Monographs on Important Clinical Subjects, in 12mo. volumes of about 
550 pages, well illustrated. The following volumes are now ready : 
Yeo on Food in Health and Disease, new (2d) edition, $2.50; Carter 
and Frost's Ophthalmic Surgery, $2.25 ; Hutchinson on Syphilis, 
$2.25 ; Marsh on Diseases of the Joints, $2 ; Owen on SurgicalDis- 
eases of Children, $2; Pick on Fractures and Dislocations, $2; Butlin 
on the Tongue, $3.50; Savage on Insanity and Allied Neuroses, $2. 
For separate notices, see under various authors' names. 

SERUES OF STUDENT'S MANUALS. See page 27. 

SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- 
SCOPICAL AND CHEMICAL METHODS. New (2d) edition. In 
one very handsome octavo volume of 530 pages, with 135 engravings 
and 14 full-page colored plates. Cloth, $3.50. Just ready. 

In all respects entirely up to date. 
— Medical Record. 

The chapter on examination of 
the urine is the most complete and 
advanced that we know of in the 
English language. — Canadian Prac- 
titioner. 



This book thoroughly deserves its 
success. It is a very complete, authen- 
tic and useful manual of the micro- 
scopical and chemical methods 
which are employed in diagnosis. 
Very excellent colored plates illus- 
trate this work. — New York Medical 
Journal. 



26 Lea Bkothers & Co., Philadelphia and New York. 



SIMON (W.). MANUAL OF CHEMISTEY. A Guide to Lectures 
and Laboratory Work for Beginners in Chemistry. A Text-book 
specially adapted for Students of Pharmacy and Medicine. New (6th) 
edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 
plates showing colors of 64 tests. Cloth, $3.00, net. Just ready. 



It is difficult to see how a better 
book could be constructed. No man 
who devotes himself to the practice 
of medicine need know more about 
chemistry than is contained between 



the covers of this book. — The North- 
western Lancet. 

Its statements are all clear and its 
teachings are practical. — Virginia 
Med. Monthly. 



SL.ADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- 
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. 



SMITH (EDWARD) 

DIABLE STAGES. 



CONSUMPTION ; ITS EARLY AND REME- 

In one 8vo. volume of 253 pp. Cloth, $2.25. 



SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- 
FANCY AND CHILDHOOD. Eighth edition, thoroughly revised 
and rewritten and much enlarged. In one large 8vo. volume of 983 
pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; 
leather, $5.50. 



The most complete and satisfac- 
tory text-book with which we are 
acquainted. — American Gynecologi- 
cal and Obstetrical Journal. 

It truly is the most evenly bal- 
anced, clear in description and 
thorough in detail of any of the 
books published in this country on 
this subject. — Medical Fortnightly. 

A treatise which in every respect 



can more than hold its own against 
any other work treating of the same 
subj ect. — American Medico-Surgical 
Bulletin. 

A safe guide for students and phy- 
sicians. — The Am. Jour, of Obstetrics. 

For years the leading text-book on 
children's diseases in America. — 
Chicago Medical Recorder. 



SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- 
oughly revised edition. In one octavo volume of 892 pages, with 
1005 engravings. Cloth, $4 ; leather, $5. 



dium for the modern surgeon. — Bos- 
ton Medical and Surgical Journal. 



One of the most satisfactory works 
on modern operative surgery yet 
published. The book is a compen- 

SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- 
TOLOGY. In one handsome octavo volume of 462 pages, with en- 
gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. 
Just ready. 
A clear and lucid summary of ■ an accurate observer and practical 
what is known of climate in relation therapeutist. — Maryland Med. Jour. 
to its influence upon human beings. Every practitioner of medicine 
— The Therapeutic Gazette. j should possess himself of a copy and 

The book is admirably planned, study it, and we are sure he will 
clearly written,and the author speaks j never regret it. — St. Louis Medical 
from an experience of thirty years as and Surgical Journal. 

STDLLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- 
ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- 
MENT, In one 12mo. volume of 163 pages, with a chart showing 
routes of previous epidemics. Cloth, $1.25. 

THERAPEUTICS AND MATERIA MEDICA. Fourth and 

revised edition. In two octavo volumes, containing 1936 pages. 
Cloth, $10 ; leather, $12. 



Lea Brothers & Co., Philadelphia and New Yoek. 27 

STIL.LE (ALFRED), MAISCH (JOHN M.) AND CASPARI 
(CHAS. JR.). THE NATIONAL DISPENSATORY: Containing 
the Natural History, Chemistry, Pharmacy, Actions and Uses of 
Medicines, including those recognized in the latest Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous refer- 
ences to the French Codex. Fifth edition, revised and enlarged, 
including the new U. S. Pharmacopoeia, Seventh Decennial Revision. 
With Supplement containing the new edition of the National Formu- 
lary. In one magnificent imperial octavo volume of about 2025 pages, 
with 320 engravings. Cloth, $7.25; leather, $8. With ready reference 
Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. 
Recommended most highly for the amount of information contained in 

physician, and invaluable to the this work is made available is indi- 

druggist. — Therapeutic Gazette. cated by the twenty-five thousand 

It is the official guide for the Med- references in the two indexes. — Bos- 

ical and Pharmaceutical professions, ton Medical and Surgical Journal. 

— Buffalo Med. and Sur. Jour. Should be recognized as a national 

The readiness with which the vast standard. — North Am. Practitioner. 

STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. 

New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 

engravings. Cloth, $3.75. 
A useful and practical guide for The book is worth the price for the 
all students and practitioners. — Am. illustrations alone. — Ohio Medical 
Journal of the Medical Sciences. Journal. 

STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND 

DISLOCATIONS. In one handsome octavo volume of 831 pages, 
with 326 engravings and 20 plates. Just ready. Cloth, $5.00, net ; 
leather, $6.00, net. 
Preeminently the authoritative I Taken as a whole, the work is the 

text-book upon the subject. The j best one in English to-day.— St. 

vast experience of the author gives j Louis Medical and Surgical Journal. 

to his conclusions an unimpeachable ; Pointed, practical, comprehensb e, 

value. The work is profusely il- i exhaustive, authoritative, well writ- 

lustrated. It will be found indis- j ten and well arranged.— Denver 

pensable to the student and the prac- j Medical Times. 

titioner alike. — The Medical Age. 

STUDENT'S QUIZ SERIES. Thirteen volumes, convenient, author- 
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13. Diseases of Children. Price, $1 each, except Nos. 1 and 7, 
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$1.75 each. Full specimen circular on application to publishers. 

STUDENT'S SERIES OF MANUALS. 12mos. of from 300-540 
pages, profusely illustrated, and bound in red limp cloth. Herman's 
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Power's Human Physiology (2d edition), $1.50; Ralfe's Clinical, 
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28 Lea Bbothers A Co., Philadelphia and New Yobk. 



STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY 
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SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE 
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TUMORS, INNOCENT AND MALIGNANT. Their Clinical 

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TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- 
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ings. Cloth, $4.25. 

TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New 
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engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Just ready. 



To the student, as to the physician, 
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and Neivs. 

It is the authority accepted as 
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ON POISONS IN RELATION TO MEDICINE AND MEDI- 
CAL JURISPRUDENCE. Third American from the third London 
edition. In one octavo volume of 788 pages, with 104 illustrations. 
Cloth, $5.50 ; leather, $6.50. 

TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- 
MENT OF VENEREAL DISEASES. New (2d) edition. In one 
very handsome octavo volume of 700 pages, with 200 engravings and 
6 colored plates. In press. 
Notices of previous edition are appended. 



By long odds the best work on 
venereal diseases. — Louisville Medi- 
cal Monthly. 

In the observation and treatment 
of venereal diseases his experience 
has been greater probably than that 
of any other practitioner of this con- 
tinent. — New York Medical Journal. 

The clearest, most unbiased and 
ably presented treatise as yet pub- 
lished on this vast subject. — The 
Medical News. 

Decidedly the most important and 
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diseases that has in recent years ap- 
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nal of the Medical Sciences. 

It is a veritable storehouse of our 
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It is commended as a conservative, 
practical, full exposition of the 
greatest value. — Chicago Clinical 
Review. 

The best work on venereal dis- 
eases in the English language. It 
is certainly above everything of the 
kind. — The St. Louis Medical and 
Surgical Journal. 



Lea Bbothers & Co., Philadelphia and New York. 29 

TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- 
UAL DISORDERS IN THE MALE AND FEMALE. In one 
8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. Clpth, 
$3. Net. Just ready. 
It is a timely boon to the medical the female is presented in an exhaus- 
profession that an observer of Dr. I tive manner, all of the causes pro- 
Taylor's skill and experience has ducing it being described. The 



written a work on this hitherto 
neglected and little understood class 
of diseases which places them on a 
scientific basis and renders them so 
clear that the physician who reads 
its pages can treat this class of 
patients intelligently. Sterility in 



author has presented to the profes- 
sion the ablest and most scientific 
work as yet published on sexual 
disorders, and one which, if carefully 
followed, will be of unlimited value 
to both physician and patient. — 
Medical News. 

—A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 
Including Diagnosis, Prognosis and Treatment. In eight large folio 
parts, measuring 14 x 18 inches, and comprising 213 beautiful figures 
on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 
pages of text. Complete work now ready. Price per part, sewed in 
heavy embossed paper, $2.50. Bound in one volume, half Russia, 
$27 ; half Turkey Morocco, $28. For sale by subscription only. Address 
the publishers. Specimen plates by mail on receipt of ten cents. 

TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 
the use of Senior Students and others. In one large 12mo. volume of 
802 pages. Cloth, $3.75. 

THOMAS (T. GAILLARD) AND MUNDE (PAUL F.). A PR AC 

TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth 
edition, thoroughly revised by Paul F. Munde, M. D. In one 
large and handsome octavo volume of 824 pages, with 347 engravings. 
Cloth, $5 ; leather, ' 



The best practical treatise on the 
subject in the English language. 
It will be of especial value to the 
general practitioner as well as to the 
specialist. The illustrations are very 
satisfactory. Many of them are new 
and are particularly clear and attrac- 
tive. — Boston Med. and Sur. Jour. 



This work, which has already gone 
through five large editions, and has 
been translated into French, Ger- 
man, Spanish and Italian, is the 
most practical and at the same time 
the most complete treatise upon the 
subject. — The Archives of Gynecol- 
ogy, Obstetrics and Pediatrics. 



THOMPSON (SLR HENRY). CLINICAL LECTURES ON DIS- 
EASES OF THE URINARY ORGANS. Second and revised edi- 
tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. 

THE PATHOLOGY AND TREATMENT OF STRICTURE 

OF THE URETHRA AND URINARY FISTULA. From the 
third English edition. In one octavo volume of 359 pages, with 47 
engravings and 3 lithographic plates. Cloth, $3.50. 

THOMSON (JOHN). DISEASES OF CHILDREN. In one crown 
octavo volume of 350 pages, with 52 illus. Cloth, $1.75, net. Just ready. 

TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- 
TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 

TREVES (FREDERICK). OPERATIVE SURGERY. In two 
8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

A SYSTEM OF SURGERY. In Contributions by Twenty-five 

English Surgeons. In two large octavo volumes. Vol. L, 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Complete work, cloth, $16.00. 



30 Lea Brothers & Co., Philadelphia and New York. 

TREVES (FREDERICK). THE STUDENTS' HANDBOOK OF 
SURGICAL OPERATIONS. In one 12mo. volume of 508 pp., with 
94 illustrations. 

SURGICAL APPLIED ANATOMY. In one 12mo. vol. of 540 pp., 



with 61 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 

TUKE (DANIEL. HACK). THE INFLUENCE OF THE MIND 
UPON THE BODY IN HEALTH AND DISEASE. Second edition. 
In one 8vo. volume of 467 pages, with 2 colored plates. Cloth, $3. 

VAUGHAN (VICTOR C.) AND NOW (FREDERICK G.). 

PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, 

or the Chemical Factors in the Causation of Disease. New (3d) edition. 
In one 12mo. volume of 603 pages. Cloth, $3. 

The work has been brought down The present edition has been not 

to date, and will be found entirely only thoroughly revised throughout 

satisfactory. — Journal of the Ameri- but also greatly enlarged, ample 

can Medical Association. consideration being given to the new 

The most exhaustive and most re- subjects of toxins and antitoxins. — 

cent presentation of the subject. — Tri-State Medical Journal. 
American Jour, of the Med. Sciences. 

VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. 
Four styles: Weekly (dated for 30 patients); Monthly (undated for 
120 patients per month) ; Perpetual (undated for 30 patients each 
week); and Perpetual (undated for 60 patients each week). The 60- 
patient book consists of 256 pages of assorted blanks. The first three 
styles contain 32 pages of important data, thoroughly revised, and 
160 pages of assorted blanks. Each in «one volume, price, $1.25. 
With thumb-letter index for quick use, 25 cents extra. Special rates 
to advance-paying subscribers to The Medical News or The 
American Journal of the Medical Sciences, or both. See p. 32. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions by H. Hartshorne, M. D. 
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 

WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- 
ING. New (3d) edition. In one 12mo. vol. of 594 pages, with 475 
engravings, many of which are photographic. Cloth, $3. 

We know of no book which more 
thoroughly or more satisfactorily 
covers the ground of Minor Surgery 
and Bandaging. — Brooklyn Medical 
Journal. 

Well written, conveniently ar- 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 



work of ready reference for sur- 
geons. — North Amer. Practitioner. 
The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist. — The Chicago Medical 
Recorder. 



Lea Brothers & Co., Philadelphia and New York. 31 



WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR 
THERAPEUTIC INDEX. Including Medical and Surgical Thera- 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 



WILLIAMS (DAWSON). THE MEDICAL DISEASES OF CHIL- 
DREN. In one 12mo. volume of 629 pages, with 18 illustrations. 
Just ready. Cloth, $2.50, net. 



The descriptions of symptoms are 
full, and the treatment recommended 
will meet general approval. Under 
each disease are given the symptoms, 



diagnoses, prognosis, complications, 
and treatment. The work is up to 
date in every sense. — The Charlotte 
Medical Journal. 



WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. 
A new and revised American from the last English edition. Illustrated 
with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; 
leather, $5. 



— THE STUDENT'S BOOK OF CUTANEOUS MEDICINE, 
one 12mo. volume. Cloth, $3.50. 



In 



WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
Translated by James R. Chadwick, A. M., M. D. With additions 
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WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated 
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YEAR-BOOK OF TREATMENT FOR 1898. A Critical Review for 
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known medical writers. 12mo., 488 pages. Cloth, $1.50. In combi- 
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YEAR-BOOKS OF TREATMENT FOR 1892, 1893, 1896 and 1897, 
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YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New 
(2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. 
Cloth, $2.50. See Series of Clinical Manuals, page 26. 

work of Dr. Yeo's. The value of 



We doubt whether any book on 
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widespread usefulness than has this 
much-quoted and much-consulted 



the work is not to be overestimated. 
— New York Medical Journal. 



A MANUAL OF MEDICAL TREATMENT, OR CLINICAL 

THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. 

YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
volume of 475 pages, with 286 illustrations. Cloth, $4 ; leather, $5. 



In studying the different chapters, 
one is impressed with the thorough- 
ness of the work. The illustrations 
are numerous — the book thoroughly 
practical — Medical News. 

It is a thorough, a very compre- 
hensive work upon this legitimate 



surgical specialty and every page 
abounds with evidences of prac- 
ticality. It is the clearest and most 
modern work upon this growing de- 
partment of surgery. — The Chicago 
Clinical Review. 



PERIODICALS. y e 



j 



PROGRESSIVE MEDICINE. 



X6. 

A Quarterly Digest of New Methods, Discoveries, and Improvements \ft' 
in the Medical and Surgical Sciences by Eminent Authorities. Edited by n 
Dr. Hobart Amory Hare. la four abundantly illustrated, cloth bound, *4 
octavo volumes, of 400-500 pages each, issued quarterly, commencing 
March 1st, 1899. Per annum (4 volumes), $10.00 delivered. 



THE MEDICAL NEWS. 

Weekly, $1.00 per Annum, 

Each number contains 32 quarto pages, abundantly illustrated, 
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THE AMERICAN JOURNAL OF THE MEDICAL. SCIENCES. 

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Each issue contains 128 octavo pages, fully illustrated. The most 
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THE MEDICAL NEWS VISITING LIST FOR 1899. 

Four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 
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year) ; and Perpetual (undated, for 60 patients per year). Each style in 
one wallet-shaped book, leather bound, with pocket, pencil and rubber. 
Price, each, $1.25. Thumb-letter index, 25 cents extra. 



THE MEDICAL NEWS POCKET FORMULARY 
FOR 1899. 

Containing 1600 prescriptions representing the latest and most ap- 
proved methods of administering remedial agents. Strongly bound in 
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COMBINATION RATES: 



American Journal of the Alone. In Combination. 

jS Medical Sciences 8 4.00 | ^ \ 

z Medical News 4.00 / $ ' - 50 t $15.00 

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g Medical News Visiting List . . . 1.25 

°- Medical News Formulary . . . 1.50 net, 

In all 820.75 for $16.00 

First four above publications in combination . . $15.75 
All above publications in combination .... 16.00 

Other Combinations will be quoted on request. 
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